Notes · payer data
Florida prior authorization scorecard: what the payers' own 2025 filings show
As of March 31, 2026, a federal rule (CMS-0057-F) requires Medicare Advantage plans, Medicaid managed-care plans, and marketplace insurers to publish their own prior authorization report cards: how many requests they received, how many they approved and denied, how many denials they reversed on appeal, and how fast they decide. The first filings — covering calendar year 2025 — are now on the payers' websites, each in its own format, in its own corner.
We pulled the primary filings for the payers that matter most to Florida specialty practices and extracted every number. This page is the comparison the filings don't give you. Every figure below comes from the payer's own posting; sources are listed at the bottom.
Read this first: these are self-reported, first-year numbers, and payers aren't perfectly comparable — they serve different members and gate different services. UnitedHealthcare's own filing notes that "not approved" includes administrative reasons like missing documentation, not only clinical denials. Read the table as a starting point with sources you can verify, not a verdict.
Medicare Advantage: the company-wide picture
Standard (non-urgent) prior authorization requests, calendar year 2025, aggregated across each payer's Medicare Advantage contracts. Where the payer disclosed request volumes, the denial rate is volume-weighted from its per-contract data; where it disclosed only percentages, we report a simple average across contracts.
| Payer | Contracts filed | Std requests | Denial rate | Denials overturned on appeal |
|---|---|---|---|---|
| UnitedHealthcare | 61 | 7.9M | 13.5% | ~55% (varies 19–88% by contract) |
| Aetna | 42 | not disclosed | ~8.4% (simple avg) | ~87% (simple avg) |
| Florida Blue Medicare (H1035 HMO / H5434 PPO) | 2 | not disclosed | 8–9% | 55–56% |
| Humana | 32 | 9.5M | 6.9% | 64.7% (volume-weighted) |
The headline sits in the first and last rows: by their own filings, UnitedHealthcare denied standard Medicare Advantage prior auth requests at roughly twice Humana's rate — 13.5% versus 6.9%, volume-weighted across 17+ million requests. And the company averages hide wide internal spreads: individual UHC contracts range from under 2% to over 23% denied.
The Florida slices
Some filings resolve to Florida directly — state-level lines of business and Florida-specific contracts. These are the rows closest to what a Florida practice actually bills against:
| Payer · line of business | Std requests | Denial rate | Overturned on appeal |
|---|---|---|---|
| UnitedHealthcare · FL marketplace (ACA) | 21,218 | 22.3% | 41.8% — of just 23 appeals filed |
| UnitedHealthcare · FL Medicaid (MMA) | 70,558 | 13.9% | 78.0% |
| UnitedHealthcare · FL Medicaid long-term care | 43,026 | 9.5% | 100% — 5 appeals filed, 5 won |
| Humana · FL Medicaid | 746,974 | 2.6% | 7.6% |
| Florida Blue · marketplace (BlueOptions/BlueSelect) | not disclosed | 5% | 28% |
| Florida Blue · marketplace (myBlue/BlueCare HMO) | not disclosed | 1% | 30% |
| Florida Blue · Medicare Advantage (HMO / PPO) | not disclosed | 9% / 8% | 55% / 56% |
The row worth rereading is the first one. On UnitedHealthcare's Florida marketplace plans, 4,732 standard requests were denied in 2025 — and 23 of those denials were appealed. That is one appeal per two hundred denials, on a book where 42% of the appeals that were filed won.
The appeal gap is the story
Across every filing we extracted, the same shape repeats: denials are common, appeals are rare, and appeals win at rates no one would call a longshot. Humana's Medicare Advantage contracts decided 17,690 appeals in 2025 and reversed 64.7% of them — against roughly 650,000 denials. Aetna's contracts report reversing over 80% of appealed denials on most contracts. Federal watchdog reports have found the same pattern for years (75–97% of appealed Medicare Advantage denials overturned, depending on service type).
A denial that would be reversed if challenged, and never is, doesn't show up anywhere as an error. It shows up as a write-off on a practice's books. The filings above put payer-published numbers on how much of that reversal capacity goes unused — which is precisely the gap a disciplined appeal operation works.
Prior auth is only half the fight
A low prior authorization denial rate does not mean claims get paid. Florida Blue's marketplace filings report PA denial rates of 1–5% — while KFF's analysis of federal transparency data puts Florida Blue among the highest in-network claim denial rates on marketplace plans, at 20%+. The authorization is approved; the claim is then denied or reduced at adjudication — bundling edits, downcoding, documentation requests, underpayment against the contracted rate.
That second fight happens on the remittance, after the service, and it's where recovery work lives. The prior auth scorecard tells you how a payer behaves at the gate; the remittance data tells you what happened to the dollars.
Who disclosed well — and who didn't
| Payer | Disclosure quality |
|---|---|
| Humana | Best in class: full request and appeal volumes per contract, plus per-state Medicaid files, all as downloadable PDFs |
| UnitedHealthcare | Strong: per-contract volumes for Medicare Advantage, state-level rows for marketplace and Medicaid |
| Aetna | Percentages only — no request volumes anywhere in an 84-page filing, which makes its rates impossible to weight |
| Florida Blue | Summary web page only: rounded percentages by product, no volumes, no downloadable file |
| Cigna | A Florida posting could not be located as of August 10, 2026 (state disclosures exist for other states) |
Granularity is itself a signal. The rule requires the metrics; it doesn't require making them easy to compare. First-year compliance ranged from genuinely transparent to the bare minimum.
What this means for a Florida practice
- Appeal more than you do. The payers' own filings say reversal rates on appealed denials run 40–90%. The scarce input is the appeal, not the winnable denial.
- Know your payer's profile. A Humana denial is comparatively rare but harder to reverse on Medicaid; a UHC denial is common and reverses often. Triage differently.
- Watch the clock, not just the rate. Every appeal window in Florida is finite and payer-specific — the working deadline table is here.
- Don't stop at the authorization. Approved-then-underpaid is the quieter pattern — Florida's 12-month underpayment rule is the backstop most practices never use.
Sources and method
All figures extracted August 10, 2026 from the payers' public CMS-0057 postings: Humana's prior authorization metrics (per-contract PDFs), UnitedHealthcare's CMS interoperability disclosures (Medicare Advantage, marketplace, and community plan files), Florida Blue's metrics page, and Aetna's 2025 PA metrics report (PDF posted on aetna.com). Company denial rates are volume-weighted where volumes were disclosed. "Overturned on appeal" is the share of decided appeals that reversed the denial — not the share of all denials. Calendar year 2025 data throughout; reporting timeframes and definitions follow each payer's filing.