Group Health Cooperative MA

Contract: H0543 · Plan type: HMO

Evidence lead: Bottom-seven record · Lower denial-rate cohort

Group Health Cooperative MA: One of the ten lowest denial rates

Group Health Cooperative MA's 4.8% rate belongs to the lowest-denial tier in this table. The exact rank is #36 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.

Bottom-seven record · Lower denial-rate cohort

One of the ten lowest denial rates

Group Health Cooperative MA's 4.8% rate belongs to the lowest-denial tier in this table. The exact rank is #36 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.

Top-three record · High overturn-rate cohort

One of the ten highest appeal overturn rates

82.0% of this contract's filed appeals were overturned in the source record. Its overturn-rate rank is #2 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.

Top-three record · Broad reversal reach

Overturned appeals covered a top-ten share of denials

661 overturned appeals equal 12.3% of every denial recorded for this contract. The cross-contract rank is #2 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.

Bottom-seven record · Low appeal-filing share

Only a small share of denials entered appeal

806 appeals correspond to 15.0% of the plan's denied requests. That is rank #33 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 request cohort

A substantial authorization workload

With 112,000 requests, this contract sits below the largest systems but above most smaller records. Its request-volume rank is #20 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.

Prior Authorization Scorecard

PA Requests
112,000
PA Denial Rate
4.8%
Appeals Filed
806
Appeal Overturn Rate
82.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 112,000
PA Approved 106,624
PA Denied 5,376
Appeals Filed 806
Appeals Overturned 661
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 Group Health Cooperative MA
What does Group Health Cooperative MA's overturn rate mean? Of the appeals filed after denials in this source record, 82% were overturned (661 of 806 filed appeals, not all 5,376 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.