Prior authorization made clear:
97.5% of Medicare Advantage medical claims do not require prior authorization1
For UnitedHealthcare Medicare Advantage (MA) plans, only 2.5% of claims require prior authorization.1 This is in place to help support clinical quality and patient safety. It’s also to confirm the service meets coverage requirements.
Prior authorization by the numbers
97.5%
of medical claims did not need prior authorization1
Only a fraction of medical claims require prior authorization
95.4%
of prior authorizations are approved2
9 out of every 10 prior authorizations submitted are approved
24 hrs
is the average time for prior authorization decisions3
Nearly all decisions are made within 1 day
Frequently asked questions about prior authorization for Medicare Advantage plans
You may have some questions about the prior authorization process. Review these answers to learn more.
For UnitedHealthcare MA plans, prior authorization requirements and reviews are informed by the Centers for Medicare & Medicaid Services (CMS) coverage policies, including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and related CMS guidance, in addition to internal medical policies using evidence-based criteria. As a result, care is delivered and then paid according to Medicare requirements, especially in situations where care and outcomes can vary.
Some services may also be reviewed when they’re widely considered investigational, experimental or unproven, or when additional safety and quality review is appropriate. For example, it may apply when therapies are provided as part of a clinical trial or for certain complex surgeries that warrant additional safety and quality review.
Prior authorization can help support high-quality, affordable care and reduce surprise costs for members by:
- Confirming coverage requirements before care is delivered
- Checking whether care is provided in the most cost-effective, appropriate, high-quality setting
For example, reviews may help direct care to a more cost-effective setting, such as an ambulatory surgical center instead of an outpatient hospital, when clinically appropriate. Nearly half of all prior authorizations are approved real-time and almost all decisions are made within 24 hours.4
We regularly evaluate prior authorization requirements and may remove them over time as CMS guidance evolves, new clinical guidelines become the standard of care and variation in care is reduced. As new evidence becomes available, requirements may also be added or updated. This approach builds on past work to remove requirements for services that consistently align with evidence-based guidelines and are almost always approved.
View Medicare Advantage prior authorization data
Reports are available to review prior authorization data for each MA H-Contract. This data being reported is consistent with the CMS Interoperability and Prior Authorization Final Rule and includes certain prior authorization and appeal information for members enrolled in UnitedHealthcare Medicare Advantage plans by H-Contract from January 1, 2025 to December 31, 2025, including prior authorization requests for transitions to post-acute care and requests submitted to capitated-delegated providers, behavioral health delegates, physical health delegates and dental delegates (where applicable). The reports do not include any reporting related to prescription drugs (not under the medical benefit). Data for non-integrated entities will be reported separately. Information is current as of the date of posting.