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2022 Prior Authorization Results
(January 1 through December 31, 2022)
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, inpatient care, surgical procedures, durable medical equipment, or medical rehabilitation
- Perscriptions (retail and medically administered)
In 2022, PreferredOne had a total of 27,684 prior authorization
cases. Of those total cases, 6,624 were submitted
electronically. Most cases (24,499) were approved and 3,185
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 359 appealed cases were
overturned after additional information was provided.
* Minnesota Statute 62M.18 ANNUAL POSTING ON WEBSITE; PRIOR AUTHORIZATIONS