SummaCare MA

Contract: H4807 · Plan type: HMO

Evidence lead: Bottom-seven record · Smaller request-volume cohort

SummaCare MA: One of the narrower authorization records

The source records 27,000 requests here, placing the contract in the smallest-volume tier. Its request-volume rank is #37 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.

Bottom-seven record · Smaller request-volume cohort

One of the narrower authorization records

The source records 27,000 requests here, placing the contract in the smallest-volume tier. Its request-volume rank is #37 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 · High appeal-filing share

Appeals followed a large share of denials

227 appeals equal 15.0% of this contract's recorded denials. That is rank #1 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-six through thirty · Lower-middle denial cohort

Below the center of the denial-rate ordering

At 5.6%, this contract sits in the lower-middle part of the observed distribution. The exact rank is #30 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 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

172 overturned appeals equal 11.4% of every denial recorded for this contract. The cross-contract rank is #9 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
27,000
PA Denial Rate
5.6%
Appeals Filed
227
Appeal Overturn Rate
76.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 27,000
PA Approved 25,488
PA Denied 1,512
Appeals Filed 227
Appeals Overturned 172
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 SummaCare MA
What does SummaCare MA's overturn rate mean? Of the appeals filed after denials in this source record, 76% were overturned (172 of 227 filed appeals, not all 1,512 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.