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Bright Health Care Prior Authorization Data State of Colorado 1/1/2020 – 7/31/2021

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Page 1: Bright Health Care Prior Authorization Data

Bright Health Care Prior Authorization DataState of Colorado 1/1/2020 – 7/31/2021

Page 2: Bright Health Care Prior Authorization Data

Summary of Medical Prior Authorization DataIndividual and Family Plan (IFP) & Medicare Advantage (MA) 1/1/2020 – 7/31/2021

Page 3: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 3

Authorizations Approvals and Denials 1/1/2020 – 7/31/2021 - IFP

Authorization Approvals/Denials - IFPAuthorization Denial Reasons - IFP

# Authorizations % Authorizations

Approved 19431 84.1%

Denied 3680 15.9%

Total 23,111 100%

0

5000

10000

15000

20000

25000

Approved Denied

Colorado IFP Authorizations

Denial Reason # Authorization Claims Review 1Criteria/Medical Necessity NOT Met 1850Lack of Information 790Member Ineligible 146Network Adequacy Available 677No Prior Approval 2Non-Covered Service 53Out of Network (MA) 23Plan Directed Care 1Reconsideration Criteria/GL NOT Met (IFP) 2Untimely Request 1Untimely Request (IFP) 134Grand Total 3680

Page 4: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 4

Authorization Requests by Procedure Category 1/1/2020 –7/31/2021- IFP

Procedure Category # of Authorizations

Cardiac Rehabilitation 4Chemotherapy 96Clinic/Office Drug Administration 150Consultation 83Day Care (Psychiatric) 69Dental Care 6Diagnostic Lab 585Diagnostic Medical 2488Dialysis 27Durable Medical Equipment Purchase 597Durable Medical Equipment Rental 178Hospice 63Maternity 394Medical Care 5292Medically Related Transportation 3MRI / CAT Scan 6880Neonatal Intensive Care 74Observation 491Occupational Therapy 13Pharmacy 5Physical Therapy 113Private Duty Nursing 1

Procedure Category # of Authorizations

Psychiatric 274Radiation Therapy 91Rehabilitation 57Skilled Nursing Care 228Speech Therapy 15Substance Abuse 231Surgical 4590Transplants 5Vision (Optometry) 8Grand Total 23111

Page 5: Bright Health Care Prior Authorization Data

Authorization Requests by Providers Specialty 1/1/2020 – 7/31/2021- IFP

Privileged & Confidential | © 20215

Provider Specialty # AuthsGastroenterology 2286Orthopedic surgery 1347General surgery 685Obstetrics/gynecology 549Internal medicine 493Hematology/oncology 459Anesthesiology 427Critical care (intensivists) 352Ophthalmology 336Physical medicine and rehabilitation 309Family practice 299Dermatology 286Hospital 269Otolaryngology 266Urology 264Diagnostic radiology 209Neurology 205Podiatry 203Unknown provider specialty 200Physician assistant 175Rheumatology 164Neurosurgery 162Medical supply company for DMERC 121Nurse practitioner 114Colorectal surgery 109Radiation oncology 79

Provider Specialty # AuthsInterventional Pain Management 73Gynecologist/oncologist 72Cardiology 70Neuropsychiatry 65Emergency medicine 64Clinical laboratory (billing independently) 56Plastic and reconstructive surgery 50Pulmonary disease 49Interventional Radiology 48Medical supply company with certified prosthetist-orthotist 47Infectious disease 43Ambulatory surgical center 36Psych/Mental Health Facility 36Pharmacy 34Pain Management 34Home Health Agency 31Pediatric medicine 30Thoracic surgery 28Certified nurse midwife 26Vascular surgery 26Nephrology 25Sleep Medicine 24Allergy / immunology 21Alcohol/Drug Abuse Treatment Facility 21Medical oncology 17Physical therapist (independently practicing) 14Dialysis Center 13

Provider Specialty # AuthsHematology 12Endocrinology 11General practice 10Sports Medicine 10Neonatology 10Dentist 10Multispecialty clinic or group practice 9Independent Diagnostic Testing Facility (IDTF) 9Clinical psychologist 7Surgical oncology 6Licensed clinical social worker 6Geriatric medicine 5Pathology 5Genetics 4Radiation Therapy Center 4Occupational therapist (independently practicing) 4Chiropractic 3Optometrist 3Hand surgery 3Supplier of oxygen and/or oxygen related equipment 3Hospice and Palliative Care 2Skilled Nursing Facility 1Psychologist (billing independently) 1Maxillofacial surgery 1Speech Language Pathologists 1All other suppliers 1

Page 6: Bright Health Care Prior Authorization Data

1st Level Appeal Outcomes 1/1/2020 – 7/31/2021 - IFP

Privileged & Confidential | © 2021 6

Appeal Outcomes - IFP

Page 7: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 7

Authorizations Approvals and Denials 1/1/2020 – 7/31/2021 - MA

Authorization Approvals/Denials - MA

Authorization Denial Reasons - MA# Authorizations % Authorizations

Approved 2651 89.4%

Denied 313 10.6%

Total 2964 100%

0

500

1000

1500

2000

2500

3000

Approved Denied

Colorado IFP Authorizations

Denial Reason # Authorization Criteria/Medical Necessity NOT Met 146Lack of Information 56Member Ineligible 21Network Adequacy Available 48Non-Covered Service 1Out of Network (MA) 26Reconsideration Criteria/GL NOT Met (IFP) 1Untimely Request (IFP) 14Grand Total 313

Page 8: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 8

Authorization Requests by Procedure Category 1/1/2020 –7/31/2021- MA

Procedure Category # of Authorizations

Cardiac Rehabilitation 1Chemotherapy 15Chiropractic 1Clinic/Office Drug Administration 35Consultation 7Day Care (Psychiatric) 2Diagnostic Lab 73Diagnostic Medical 189Dialysis 13Durable Medical Equipment Purchase 61Durable Medical Equipment Rental 82Hospice 42Medical Care 748Medically Related Transportation 2MRI / CAT Scan 808Observation 71Occupational Therapy 10Physical Therapy 70Psychiatric 12

Procedure Category # of Authorizations

Radiation Therapy 7Rehabilitation 25Skilled Nursing Care 220Speech Therapy 1Substance Abuse 1Surgical 466Vision (Optometry) 2Grand Total 2964

Page 9: Bright Health Care Prior Authorization Data

Authorization Requests by Providers Specialty 1/1/2020 – 7/31/2021- MA

Privileged & Confidential | © 2021 9

Provider Specialty # AuthsOrthopedic surgery 111Ophthalmology 85Anesthesiology 77Internal medicine 77Hematology/oncology 74Gastroenterology 65Dermatology 55Critical care (intensivists) 53Physical medicine and rehabilitation 53Family practice 51Diagnostic radiology 42General surgery 39Hospital 37Medical supply company for DMERC 32Home Health Agency 31Urology 30Cardiology 26Neurology 24Podiatry 22Nurse practitioner 22Unknown provider specialty 21Otolaryngology 19Neurosurgery 18Radiation oncology 13

Provider Specialty # AuthsPhysician assistant 11Rheumatology 10Dialysis Center 10Pulmonary disease 8Emergency medicine 6Geriatric medicine 6Obstetrics/gynecology 6Interventional Pain Management 6Vascular surgery 5Ambulatory surgical center 5Thoracic surgery 5Gynecologist/oncologist 5Medical oncology 5Pain Management 4Neuropsychiatry 4Infectious disease 4Independent Diagnostic Testing Facility (IDTF) 3Interventional Radiology 3Medical supply company with certified prosthetist-orthotist 3Nephrology 2Sleep Medicine 2Physical therapist (independently practicing) 2

Provider Specialty # AuthsEndocrinology 2Supplier of oxygen and/or oxygen related equipment 2Plastic and reconstructive surgery 2Audiologist (billing independently) 2Pathology 1Clinical psychologist 1Clinical laboratory (billing independently) 1Skilled Nursing Facility 1Psych/Mental Health Facility 1Ambulance service supplier 1Optometrist 1Chiropractic 1

Page 10: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 10

1st Level Appeal Outcomes 1/1/2020 – 7/31/2021 - MA

Appeal Outcomes - MA

Page 11: Bright Health Care Prior Authorization Data

Summary of Pharmacy Prior Authorization DataIndividual and Family Plan (IFP) & Medicare Advantage (MA) 1/1/2020 – 7/31/2021

Page 12: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 12

Authorizations Approvals and Denials 1/1/2020 – 7/31/2021 - IFP

Authorization Approvals/Denials - IFP

Authorization Denial Reasons - IFP

Page 13: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 13

Authorization Requests by Provider Specialty 1/1/2020 –7/31/2021- IFP

Page 14: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 14

1st Level Appeal Outcomes 1/1/2020 – 7/31/2021 - IFP

Appeal Outcomes - IFP

Page 15: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 15

Authorizations Approvals and Denials 1/1/2020 – 7/31/2021 - MA

Authorization Approvals/Denials - MA

Authorization Denial Reasons - MA

Page 16: Bright Health Care Prior Authorization Data

Authorization Requests by Providers Specialty 1/1/2020 – 7/31/2021- MA

Privileged & Confidential | © 2021 16

Page 17: Bright Health Care Prior Authorization Data

Privileged & Confidential | © 2021 17

1st Level Appeal Outcomes 1/1/2020 – 7/31/2021 - MA

Appeal Outcomes - MA


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