Prior Authorization metrics for medical items and services (excluding drugs)

To comply with the CMS Interoperability and Prior Authorization final rule, Capital Blue Cross 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 us.

Reporting period: 2025

For medical items and services for which we require prior authorization (excluding drugs), refer to our single source preauthorization list.

Beginning January 1, 2026, the CMS Interoperability and Prior Authorization final rule updated certain timeframes for sending prior authorization decisions; however, CHIP managed care organizations must continue to follow Pennsylvania Act 146. Decision timeframes remain:

Standard (non-urgent) Prior Authorization requests (Response due to Provider within 2 business days)

Expedited (urgent) Prior Authorization requests (Response due to Provider within 2 business days)

Results based on limited data should be interpreted with caution. Outcomes are expected to stabilize as more data becomes available.