SCAN Health Plan

Contract: H5599 · Plan type: HMO

Evidence lead: Ranks seven through ten · High appeal-filing share

SCAN Health Plan: Appeals followed a large share of denials

1,693 appeals equal 15.0% of this contract's recorded denials. That is rank #7 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 seven through ten · High appeal-filing share

Appeals followed a large share of denials

1,693 appeals equal 15.0% of this contract's recorded denials. That is rank #7 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 seven through ten · High overturn-rate cohort

One of the ten highest appeal overturn rates

76.0% of this contract's filed appeals were overturned in the source record. Its overturn-rate rank is #8 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 seven through ten · Broad reversal reach

Overturned appeals covered a top-ten share of denials

1,286 overturned appeals equal 11.4% of every denial recorded for this contract. The cross-contract rank is #8 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 twenty-six through thirty · Lower-middle denial cohort

Below the center of the denial-rate ordering

At 6.1%, this contract sits in the lower-middle part of the observed distribution. The exact rank is #27 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 request cohort

A substantial authorization workload

With 185,000 requests, this contract sits below the largest systems but above most smaller records. Its request-volume rank is #14 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
185,000
PA Denial Rate
6.1%
Appeals Filed
1,693
Appeal Overturn Rate
76.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 185,000
PA Approved 173,715
PA Denied 11,285
Appeals Filed 1,693
Appeals Overturned 1,286
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 SCAN Health Plan
What does SCAN Health Plan's overturn rate mean? Of the appeals filed after denials in this source record, 76% were overturned (1,286 of 1,693 filed appeals, not all 11,285 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.