Tufts Health Plan MA

Contract: H1245 · Plan type: PPO

Evidence lead: Ranks four through six · High appeal-filing share

Tufts Health Plan MA: Appeals followed a large share of denials

927 appeals equal 15.0% of this contract's recorded denials. That is rank #5 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 four through six · High appeal-filing share

Appeals followed a large share of denials

927 appeals equal 15.0% of this contract's recorded denials. That is rank #5 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 reversal reach

Reversals covered a below-median share of denials

The 630 recorded reversals amount to 10.2% of this contract's denied requests. The cross-contract rank is #25 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-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 · Moderate request-volume cohort

A mid-lower authorization workload

This contract's 87,000 requests form a moderate comparison base within the table. Its request-volume rank is #22 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 sixteen through twenty · Upper-middle denial cohort

Above the center of the denial-rate ordering

The recorded 7.1% denial rate falls in the upper-middle portion of the contract set. The exact rank is #19 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.

Prior Authorization Scorecard

PA Requests
87,000
PA Denial Rate
7.1%
Appeals Filed
927
Appeal Overturn Rate
68.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 87,000
PA Approved 80,823
PA Denied 6,177
Appeals Filed 927
Appeals Overturned 630
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 Tufts Health Plan MA
What does Tufts Health Plan MA's overturn rate mean? Of the appeals filed after denials in this source record, 68% were overturned (630 of 927 filed appeals, not all 6,177 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.