2021 Prior Authorization Results

(January 1 through December 31, 2021)

Minnesota health plans are required to share prior authorization data. Prior authorization is when a care provider or member checks in advance if certain services are medically necessary and appropriate and covered under the health plan.

Examples of services that require prior authorization include but are not limited to certain:

  • Behavioral health and substance abuse (BH/SA)
  • Medical services, for example, outpatient care, durable medical equipment, outpatient or inpatient rehabilitation (Medical)
  • Prescriptions (Med Rx)
  • Surgical procedures, for example, inpatient or outpatient (Surgical)

In 2021, PreferredOne had a total of 29,395 prior authorization cases. Of those total cases, 4,186 were submitted electronically. Most cases (27,073) were approved and 2,322 were initially denied.

Services Denied Breakdown

The most common reason for denying services was that the procedure did not meet medical criteria. In other words, there may be more appropriate ways to treat the member. Another common reason for denial was the member’s care provider did not include enough information when requesting the review. In other cases, the request is made for a service that is not covered under a member’s health benefits.

If a member or care provider disagrees with PreferredOne’s review determination, the case can be appealed. In such cases, the member or care provider may share more information that helps PreferredOne better evaluate the request. The chart shows that 465 appealed cases were overturned after additional information was provided.