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CMS Requirement for Preauthorization Metrics
Last updated: 3/31/2026
The Centers for Medicare and Medicaid (CMS) requires EmblemHealth to annually report aggregated preauthorization metrics on our website to comply with the CMS Interoperability and Prior Authorization final rule (CMS-0057-F January 17, 2024).
This final rule emphasizes the need to improve the exchange of health information to achieve appropriate and necessary access to health records for patients, healthcare providers, and payers. This final rule also focuses on efforts to improve preauthorization processes through policies and technology, to help ensure that patients remain at the center of their own care.*
The metrics must include a list of all medical items and services (excluding drugs) that require preauthorization and data on the preauthorization 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 the preauthorization process.
- Enables providers to evaluate payer performance.
Additionally, the metrics can be used to compare plans, programs, and payers.
*Centers for Medicaid and Medicare – CMS.gov.
Reporting Period: 2025
These are the medical items and services for which we require preauthorization (excluding drugs).
EmblemHealth Medicare H3330
Standard (non-urgent) Preauthorization Requests
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
67,575 |
73,246 |
92.3% |
Request denied |
5,671 |
73,246 |
7.7% |
Request approved only after time for review was extended |
51 |
73,246 |
0.1% |
Request approved only after appeal |
353 |
73,246 |
0.5% |
Expedited (urgent) Preauthorization Requests
(Response Due to Provider Within 72 Hours)
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
2,498 |
2,958 |
84.4% |
Request denied |
460 |
2,958 |
15.6% |
Request approved only after time for review was extended |
17 |
2,958 |
0.6% |
Request approved only after appeal |
20 |
2,958 |
0.7% |
Time Between Receiving a Preauthorization Request and Sending a Decision
|
Mean (Average) Time |
Median (Middle) Time |
Standard (non-urgent) Preauthorization Requests (response due to provider within 7 calendar days) |
1.3 days |
17.0 days |
Expedited (urgent) Preauthorization Requests (response due to provider within 72 hours) |
0.4 days |
4.5 days |
EmblemHealth Medicare H5991
Standard (non-urgent) Preauthorization Requests
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
4,309 |
5,009 |
86.0% |
Request denied |
700 |
5,009 |
14.0% |
Request approved only after time for review was extended |
4 |
5,009 |
0.1% |
Request approved only after appeal |
50 |
5,009 |
1.0% |
Expedited (urgent) Preauthorization Requests
(Response Due to Provider Within 72 Hours)
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
126 |
154 |
81.8% |
Request denied |
28 |
154 |
18.2% |
Request approved only after time for review was extended |
4 |
154 |
2.6% |
Request approved only after appeal |
0 |
154 |
0.0% |
Time Between Receiving a Preauthorization Request and Sending a Decision
|
Mean (Average) Time |
Median (Middle) Time |
Standard (non-urgent) Preauthorization Requests (response due to provider within 7 calendar days) |
1.9 days |
15.0 days |
Expedited (urgent) Preauthorization Requests (response due to provider within 72 hours) |
0.6 days |
3.0 days |
EmblemHealth Medicare H5228
Standard (non-urgent) Preauthorization Requests
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
25 |
29 |
86.2% |
Request denied |
4 |
29 |
13.8% |
Request approved only after time for review was extended |
0 |
29 |
0.0% |
Request approved only after appeal |
0 |
29 |
0.0% |
Expedited (urgent) Preauthorization Requests
(Response Due to Provider Within 72 Hours)
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
2 |
2 |
100.0% |
Request denied |
0 |
2 |
0.0% |
Request approved only after time for review was extended |
0 |
2 |
0.00% |
Request approved only after appeal |
0 |
2 |
0.0% |
Time Between Receiving a Preauthorization Request and Sending a Decision
|
Mean (Average) Time |
Median (Middle) Time |
Standard (non-urgent) Preauthorization Requests (response due to provider within 7 calendar days) |
2.1 days |
5.5 days |
Expedited (urgent) Preauthorization Requests (response due to provider within 72 hours) |
0.0 days |
0.0 days |
EmblemHealth CHP
Standard (non-urgent) Preauthorization Requests
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
4,986 |
6,070 |
82.1% |
Request denied |
1,084 |
6,070 |
17.9% |
Request approved only after time for review was extended |
3 |
6,070 |
0.05% |
Request approved only after appeal |
53 |
6,070 |
0.9% |
Expedited (urgent) Preauthorization Requests
(Response Due to Provider Within 72 Hours)
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
101 |
122 |
82.8% |
Request denied |
21 |
122 |
17.2% |
Request approved only after time for review was extended |
0 |
122 |
0.0% |
Request approved only after appeal |
1 |
122 |
0.8% |
Time Between Receiving a Preauthorization Request and Sending a Decision
|
Mean (Average) Time |
Median (Middle) Time |
Standard (non-urgent) Preauthorization Requests (response due to provider within 7 calendar days) |
2.1 days |
22.5 days |
Expedited (urgent) Preauthorization Requests (response due to provider within 72 hours) |
0.2 days |
1.5 days |
EmblemHealth Medicaid and HARP
Standard (non-urgent) Preauthorization Requests
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
89,358 |
115,230 |
77.5% |
Request denied |
25,872 |
115,230 |
22.5% |
Request approved only after time for review was extended |
196 |
115,230 |
0.2% |
Request approved only after appeal |
546 |
115,230 |
0.5% |
Expedited (urgent) Preauthorization Requests
(Response Due to Provider Within 72 Hours)
|
How many times this happened |
Out of total requests |
Percentage |
Request approved |
4,574 |
5,302 |
86.3% |
Request denied |
728 |
5,302 |
13.7% |
Request approved only after time for review was extended |
12 |
5,302 |
0.2% |
Request approved only after appeal |
21 |
5,302 |
0.4% |
Time Between Receiving a Preauthorization Request and Sending a Decision
|
Mean (Average) Time |
Median (Middle) Time |
Standard (non-urgent) Preauthorization Requests (response due to provider within 7 calendar days) |
2.1 days |
57.0 days |
Expedited (urgent) Preauthorization Requests (response due to provider within 72 hours) |
0.5 days |
11.0 days
|
JP 71357 3/2026