Capital BlueCross MA

Contract: H5216 · Plan type: HMO

Evidence lead: Ranks eleven through fifteen · Upper-middle appeal uptake

Capital BlueCross MA: Appeal filing exceeded most contract records

The 969 filed appeals represent 15.0% of denied requests. That is rank #11 of 37 for filing share. The ratio reports aggregate activity; it cannot reveal why an appeal was or was not filed, whether the underlying cases were comparable, or what happened outside the reporting window.

Ranks eleven through fifteen · Upper-middle appeal uptake

Appeal filing exceeded most contract records

The 969 filed appeals represent 15.0% of denied requests. That is rank #11 of 37 for filing share. The ratio reports aggregate activity; it cannot reveal why an appeal was or was not filed, whether the underlying cases were comparable, or what happened outside the reporting window.

Ranks twenty-one through twenty-five · Moderate request-volume cohort

A mid-lower authorization workload

This contract's 95,000 requests form a moderate comparison base within the table. Its request-volume rank is #21 of 37. Volume shows the denominator behind approvals and denials; it is not a measure of plan quality, membership, benefit breadth, price, or future coverage decisions.

Ranks twenty-one through twenty-five · Lower-middle denial cohort

Below the center of the denial-rate ordering

At 6.8%, this contract sits in the lower-middle part of the observed distribution. The exact rank is #21 of 37. This is aggregate prior-authorization activity for the reporting window, not a probability that a particular service, drug, or beneficiary request will be denied.

Ranks twenty-one through twenty-five · Lower-middle overturn cohort

Appeal overturns sat below the table midpoint

This contract records a 69.0% overturn rate among filed appeals. Its overturn-rate rank is #21 of 37. The denominator is filed appeals, not all authorization requests. The percentage therefore describes reviewed appeals and must not be read as an individual outcome forecast.

Ranks twenty-one through twenty-five · Lower-middle reversal reach

Reversals covered a below-median share of denials

The 669 recorded reversals amount to 10.4% of this contract's denied requests. The cross-contract rank is #21 of 37. This derived measure combines appeal filing and outcome, so it supplies scale context but does not identify clinical reasons, administrative errors, or coverage rules.

Prior Authorization Scorecard

PA Requests
95,000
PA Denial Rate
6.8%
Appeals Filed
969
Appeal Overturn Rate
69.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 95,000
PA Approved 88,540
PA Denied 6,460
Appeals Filed 969
Appeals Overturned 669
Source: CMS Office of Inspector General report OEI-09-22-00380; KFF 2023 Medicare Advantage analysis. Verify with HHS OIG → · CMS.gov →
Sources, caveats, and related notes for Capital BlueCross MA
What does Capital BlueCross MA's overturn rate mean? Of the appeals filed after denials in this source record, 69% were overturned (669 of 969 filed appeals, not all 6,460 denied requests).
This data is for informational purposes only and does not constitute medical, financial, or insurance advice. Contact CMS or your plan for coverage decisions. Data from CMS OIG and KFF Medicare Advantage analysis.

Data: CMS OIG OEI-09-22-00380 and KFF 2023 Medicare Advantage analysis. Not affiliated with CMS. ← All MA plans

Read our methodology - how this data is sourced, computed, and verified.

Primary data: U.S. Department of Health & Human Services, Office of Inspector General, Medicare Advantage Encounter Data (Report OEI-09-22-00380, 2024). Secondary data: Kaiser Family Foundation 2023 Medicare Advantage Prior Authorization analysis. Methodology and editorial review by PlainInsurer, see methodology.