WellCare Florida MA

Contract: H3499 · Plan type: HMO

Evidence lead: Top-three record · Higher denial-rate cohort

WellCare Florida MA: A top-ten denial rate in this source set

WellCare Florida MA's 15.2% denial rate is in the highest group of the comparison. The exact rank is #1 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.

Top-three record · Higher denial-rate cohort

A top-ten denial rate in this source set

WellCare Florida MA's 15.2% denial rate is in the highest group of the comparison. The exact rank is #1 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.

Bottom-seven record · Lower overturn-rate cohort

One of the ten lowest appeal overturn rates

57.0% of filed appeals were overturned, placing this record in the lowest-rate tier. Its overturn-rate rank is #36 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.

Bottom-seven record · Narrow reversal reach

Overturned appeals covered a small share of denials

8.6% of the plan's denials were ultimately overturned through the appeals counted here. The cross-contract rank is #36 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 seven through ten · Large request-volume cohort

One of the ten largest authorization workloads

The 290,000 recorded requests place this contract in the highest-volume tier. Its request-volume rank is #10 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 eleven through fifteen · Upper-middle appeal uptake

Appeal filing exceeded most contract records

The 6,612 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.

Prior Authorization Scorecard

PA Requests
290,000
PA Denial Rate
15.2%
Appeals Filed
6,612
Appeal Overturn Rate
57.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 290,000
PA Approved 245,920
PA Denied 44,080
Appeals Filed 6,612
Appeals Overturned 3,769
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 WellCare Florida MA
What does WellCare Florida MA's overturn rate mean? Of the appeals filed after denials in this source record, 57% were overturned (3,769 of 6,612 filed appeals, not all 44,080 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.