Medicare Advantage prior authorization metrics
For medical items and services (excluding drugs).
To comply with the CMS Interoperability and Prior Authorization final rule, Mass General Brigham Health Plan is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers. For questions on the data below, contact:
Medicare Advantage Customer Service
Email: HealthPlanMedAdvCustomerService@mgb.org
Call: 855-833-3668 (TTY 711)
Hours:
October 1 - March 31
8 a.m. to 8 p.m. ET, Monday-Sunday
April 1 - September 30
8 a.m. to 8 p.m. ET, Monday-Friday
Reporting period: 2025
Mass General Brigham Health Plan Medicare Advantage members can find the medical items and services for which we require prior authorization at the link below.
Prior to January 1, 2026, MA plans and applicable integrated plans are required to send prior authorization decisions within 72 hours for expedited requests (urgent) and 14 calendar days for standard requests (non-urgent).
Beginning January 1, 2026, the CMS Interoperability and Prior Authorization final rule requires Medicare Advantage plans to send prior authorization decisions within:
- 72 hours for expedited requests (urgent)
- 7 calendar days for standard requests (non-urgent)
Standard (non-urgent) prior authorization requests
| How many times this happened | Out of total requests | Percentage | |
| Request approved | 10137 | 11482 | 88.29% |
| Request denied | 1345 | 11482 | 11.71% |
| Request approved only after time for review was extended | 0 | 11482 | 0% |
| Request approved only after appeal | 121 | 173 | 69.94% |
| How many times this happened | Out of total requests | Percentage | |
| Request approved | 1739 | 1954 | 89% |
| Request denied | 215 | 1954 | 11% |
| Request approved only after time for review was extended | 0 | 1954 | 0% |
| Request approved only after appeal | 25 | 37 | 67.57% |
Expedited (urgent) prior authorization requests
Response due to provider within 72 hours
| How many times this happened | Out of total requests | Percentage | |
| Request approved | 1035 | 1121 | 92.33% |
| Request denied | 86 | 1121 | 7.67% |
| Request approved only after time for review was extended | 3 | 1121 | 0.27% |
| How many times this happened | Out of total requests | Percentage | |
| Request approved | 172 | 181 | 95.03% |
| Request denied | 9 | 181 | 4.97% |
| Request approved only after time for review was extended | 1 | 181 | 0.55% |
Time between receiving a prior authorization request and sending a decision
| Mean (average) time | Median (middle) time | |
| Standard (non-urgent) prior authorization requests (response due to provider within 7 calendar days) | 4 days, 16 hours | 1 day, 1 hour |
| Expedited (urgent) prior authorization requests (response due to provider within 72 hours) | 45 hours | 31 hours |
| Mean (average) time | Median (middle) time | |
| Standard (non-urgent) prior authorization requests (response due to provider within 7 calendar days) | 7 days, 7 hours | 1 day, 1 hour |
| Expedited (urgent) prior authorization requests (response due to provider within 72 hours) | 36 hours | 30 hours |
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Last updated: 10/1/2025
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