Prior Auth Reporting

Jefferson Health Plans publicly reports prior authorization metrics in accordance with CMS Interoperability
and Prior Authorization Final Rule (CMS-0057-F).

Metrics by Line of Business
Standard and Expedited Prior Authorization metrics

Standard Prior Authorization (Non-Urgent):
Response due within 14 days

Expedited Prior Authorization (Urgent)
Response due within 3 calendar days

Standard and Expedited Prior Authorization metrics

Standard Prior Authorization (Non-Urgent):
Response due within 14 days

Expedited Prior Authorization (Urgent)
Response due within 3 calendar days

Methodology and Definitions

All prior authorization data is sourced from the Jefferson Health Plan utilization management system (MHK), Davis, Evicore, Magellan, Avesis. Metrics reflect Calendar Year 2025 activity and represent final authorization decisions recorded during that period.

This report includes non-drug medical prior authorization requests across all service categories, including:

  • Inpatient services
  • Outpatient services
  • Durable Medical Equipment (DME)
  • Other non-prescription medical services

Prescription drug prior authorizations are excluded from this report.

Requests are categorized based on their recorded priority at the time of submission:

  • Standard (Non-Urgent): Reported as classified in the system
  • Expedited: Reported as classified in the system
  • Urgent: Counted as Expedited for reporting purposes

Metrics include all Lines of Business (LOBs) administered by Jefferson Health Plan during the reporting period. No LOBs are excluded unless otherwise noted in supplemental materials.

Reported metrics reflect final decision outcomes for each authorization request:

  • Approved: Requests fully approved as submitted
  • Denied: Requests denied in full
  • Partially Approved: Counted as Denied for reporting purposes

To ensure that reported denial rates reflect meaningful clinical determinations, certain administrative or non-clinical outcomes are excluded from denial counts. Requests with the following Decisions are filtered out:

  • Duplicate 
  • No PA required
  • Data Entry error 
  • Requested in error 
  • Void 
  • Withdrawn