EmblemHealth

Contract: H0755 · Plan type: HMO

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

EmblemHealth: Appeal filing exceeded most contract records

The 1,443 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 1,443 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 sixteen through twenty · Upper-middle denial cohort

Above the center of the denial-rate ordering

The recorded 7.4% denial rate falls in the upper-middle portion of the contract set. The exact rank is #16 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 reversal reach

Reversals covered a below-median share of denials

The 996 recorded reversals amount to 10.4% of this contract's denied requests. The cross-contract rank is #22 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.

Ranks sixteen through twenty · Upper-middle request cohort

A substantial authorization workload

With 130,000 requests, this contract sits below the largest systems but above most smaller records. Its request-volume rank is #17 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 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.

Prior Authorization Scorecard

PA Requests
130,000
PA Denial Rate
7.4%
Appeals Filed
1,443
Appeal Overturn Rate
69.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 130,000
PA Approved 120,380
PA Denied 9,620
Appeals Filed 1,443
Appeals Overturned 996
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 EmblemHealth
What does EmblemHealth's overturn rate mean? Of the appeals filed after denials in this source record, 69% were overturned (996 of 1,443 filed appeals, not all 9,620 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.