Humana

Contract: H0630 · Plan type: HMO

Evidence lead: Top-three record · Large request-volume cohort

Humana: One of the ten largest authorization workloads

The 1,450,000 recorded requests place this contract in the highest-volume tier. Its request-volume rank is #2 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.

Top-three record · Large request-volume cohort

One of the ten largest authorization workloads

The 1,450,000 recorded requests place this contract in the highest-volume tier. Its request-volume rank is #2 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 seven through ten · Higher denial-rate cohort

A top-ten denial rate in this source set

Humana's 10.4% denial rate is in the highest group of the comparison. The exact rank is #7 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 eleven through fifteen · Upper-middle appeal uptake

Appeal filing exceeded most contract records

The 22,620 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 · Lower-middle overturn cohort

Appeal overturns sat below the table midpoint

This contract records a 68.0% overturn rate among filed appeals. Its overturn-rate rank is #24 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 15,382 recorded reversals amount to 10.2% of this contract's denied requests. The cross-contract rank is #24 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
1,450,000
PA Denial Rate
10.4%
Appeals Filed
22,620
Appeal Overturn Rate
68.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 1,450,000
PA Approved 1,299,200
PA Denied 150,800
Appeals Filed 22,620
Appeals Overturned 15,382
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 Humana
What does Humana's overturn rate mean? Of the appeals filed after denials in this source record, 68% were overturned (15,382 of 22,620 filed appeals, not all 150,800 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.