Prior Authorization Reporting

Prior authorization

Some medical services and treatments need to be approved by your health plan as "medically necessary" before you can get them. Your primary care provider (PCP) or other health care provider must get approval from your health plan — this is called “prior authorization.” This process helps make sure you get the care you need, as well as helping to stop fraud, waste, and abuse.

Both expedited and standard prior authorizations must be completed as soon as possible. We will consider your medical needs. We will complete the authorization within two business days of receiving it.

To view a list of services that require prior authorization, see the How to Use Your Health Plan section in the Evidence of Coverage linked below.

View services requiring prior authorization

Centers for Medicare & Medicaid Services (CMS) requirement

Every year, First Choice Next must provide data on our website about how many prior authorizations were submitted and approved or denied. The report must be posted by March 31. This reporting is part of CMS Interoperability and Prior Authorization Final Rule CMS-0057-F.

 

First Choice Next 2025 Prior Authorization Report

 

Expedited and Standard authorizations

  • Total requests received: 3,739
  • Total requests approved: 2,743
  • Total requests approved other than requested:* 186
  • Total requests approved after appeal (overturned): 33
  • Total requests denied: 810
  • Percentage approved: 73.36%
  • Percentage denied: 21.66%
  • Percentage approved other than requested: 4.97%
  • Percentage approved after appeal (overturned): 0.88%
  • Average number of days to notification of decision: 1.91
  • Average number of hours to notification of decision: N/A
  • Median number of days to notification of decision: 1
  • Median number of hours to notification of decision: N/A
  • Percentage of approved standard requests where the time frame was extended:** 0.4%
  • Percentage of approved expedited requests where the time frame was extended: N/A

* Refers to requests in which a portion of the request was not approved.

** Refers to the additional days allowed to complete the medical necessity review and the determination notice.