Medicaid 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:
Mass General Brigham ACO Customer Service
Email: HealthPlanCustomerService-Members@mgb.org
Call: 800-462-5449 (TTY 711)
Hours: Monday through Friday, 8:00 AM to 6:00 PM and Thursdays 8:00 AM to 8:00 PM
Reporting period: 2025
Mass General Brigham ACO members can find the medical items and services for which we require prior authorization at the links below.
- Prior Authorization, Notification, and Referral Guidelines (PDF)
- Prior Authorization required for DME, medical supplies, oxygen-related equipment, orthotics, prosthetics, and hearing aids (PDF)
Prior to January 1, 2026, Medicaid managed care plans and CHIP managed care entities 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 Medicaid managed care 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 | 37180 | 41373 | 89.87% |
| Request denied | 4193 | 41373 | 10.13% |
| Request approved only after time for review was extended | 1 | 41373 | 0% |
| Request approved only after appeal | 51 | 208 | 24.52% |
Expedited (urgent) prior authorization requests
Response due to provider within 72 hours
| How many times this happened | Out of total requests | Percentage | |
| Request approved | 9170 | 9489 | 96.64% |
| Request denied | 319 | 9489 | 3.36% |
| Request approved only after time for review was extended | 0 | 9489 | 0% |
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) | 5 days, 5 hours | 1 day, 9 hours |
| Expedited (urgent) prior authorization requests (response due to provider within 72 hours) | 55 hours | 29 hours |
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