Jefferson Health Plans · Interoperability

Prior Authorization Metrics, 2025

Outcomes and decision times for every prior authorization request in calendar year 2025, by line of business. These are the figures Jefferson Health Plans publishes under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).

At a glance

Metrics by Line of Business

Methodology and Definitions

Data Source and Reporting Period

All prior authorization data is sourced from the Jefferson Health Plan utilization management systems.

Metrics reflect Calendar Year 2025 activity and represent final authorization decisions recorded during that period.

Priority Authorization Priority Classification

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

Scope of Services Included
  • Inpatient services
  • Outpatient services
  • Durable Medical Equipment (DME)
  • Other non-prescription medical services

Prescription drug prior authorizations are excluded from this report.

Decision Status Definitions

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

Excluded Administrative Outcomes

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  • Withdrawn