Prior Authorization Metrics for Medical Items and Services

Marketplace Prior Authorization Metrics for Medical Items and Services (Excluding Drugs)

To comply with the CMS Interoperability and Prior Authorization final rule, SummaCare 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: contactproviderservices@summacare.com.

Reporting Period: 2025

A list of the medical items and services for which we require prior authorization (excluding drugs) can be found on Plan Central.

Prior to January 1, 2026, impacted payers are required to send prior authorization decisions within the following timeframes:

• For MA plans, and applicable integrated plans, 72 hours for expedited requests (urgent) and seven calendar days for standard requests (non-urgent)
• For QHP issuers on the FFEs, 72 hours for expedited requests (urgent) and seven 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)
• Seven calendar days for standard requests (non-urgent)