UPMC Health Plan MA

Contract: H2762 · Plan type: HMO

Evidence lead: Ranks twenty-six through thirty · Lower-middle appeal uptake

UPMC Health Plan MA: Appeal filing trailed the table midpoint

Filed appeals account for 15.0% of this contract's denials, or 1,427 records. That is rank #27 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 appeal uptake

Appeal filing trailed the table midpoint

Filed appeals account for 15.0% of this contract's denials, or 1,427 records. That is rank #27 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 eleven through fifteen · Upper-middle overturn cohort

Appeal overturns ran above most contracts

The observed overturn rate is 73.0%, in the upper-middle portion of the table. Its overturn-rate rank is #14 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 eleven through fifteen · Upper-middle reversal reach

Reversals covered an above-median share of denials

Overturned appeals represent 11.0% of all denials here, based on 1,042 reversals. The cross-contract rank is #14 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 sixteen through twenty · Upper-middle request cohort

A substantial authorization workload

With 142,000 requests, this contract sits below the largest systems but above most smaller records. Its request-volume rank is #16 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 twenty-one through twenty-five · Lower-middle denial cohort

Below the center of the denial-rate ordering

At 6.7%, this contract sits in the lower-middle part of the observed distribution. The exact rank is #22 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
142,000
PA Denial Rate
6.7%
Appeals Filed
1,427
Appeal Overturn Rate
73.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 142,000
PA Approved 132,486
PA Denied 9,514
Appeals Filed 1,427
Appeals Overturned 1,042
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 UPMC Health Plan MA
What does UPMC Health Plan MA's overturn rate mean? Of the appeals filed after denials in this source record, 73% were overturned (1,042 of 1,427 filed appeals, not all 9,514 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.