Prior authorization made clear:
96.6% of ACA Marketplace plan medical claims do not require prior authorization1
For UnitedHealthcare Individual & Family ACA Marketplace plans, only 3.4% of claims require prior authorization.1 This is in place to help support clinical quality and patient safety. It’s also to confirm the service meets coverage requirements.
Prior authorization by the numbers
96.6%
of medical claims did not need prior authorization1
Only a fraction of medical claims require prior authorization
80.3%
of prior authorizations were approved2
8 out of every 10 prior authorizations submitted are approved
24 hrs
is the average time for prior authorization decisions3
Nearly all decisions are made within 1 day
Frequently asked questions about prior authorization for UnitedHealthcare ACA Marketplace plans
You may have some questions about the prior authorization process. Review these answers to learn more.
Some procedures are reviewed because they’re widely considered investigational, experimental or unproven. For example, it may apply when therapies are provided as part of a clinical trial. Another example is when there are certain complex surgeries that prompt additional safety and quality review.
Prior authorization can help support high quality, affordable care and reduce surprise costs for members by:
- Confirming coverage requirements before care is delivered
- Checking whether care is provided in the most cost-effective, appropriate, high-quality setting
For example, reviews may help direct care to a more cost-effective setting, such as an ambulatory surgical center instead of an outpatient hospital, when clinically appropriate. Nearly half of all prior authorizations are approved in real-time and almost all decisions are made within 24 hours.4
Differences in prior authorization approval rates across products can reflect the characteristics of each line of business. For UnitedHealthcare Individual & Family ACA Marketplace plans, approval rates can be influenced by factors such as network structure and benefit design.
These differences do not reflect a single cause, but rather the way UnitedHealthcare Individual & Family ACA Marketplace products are designed and used compared to other lines of business, which can affect the types of services requested and how prior authorization is applied in practice.
We regularly evaluate prior authorization requirements. We may remove requirements over time as clinical guidelines become the standard of care and variation in care is reduced. As new evidence becomes available, requirements may also be added or updated. This approach builds on past removals for services that consistently align with evidence-based guidelines and are almost always approved.
We always follow applicable federal and state requirements related to the prior authorization process. This includes mental health parity rules that help ensure prior authorization is applied fairly and consistently.
View prior authorization data for UnitedHealthcare ACA Marketplace plans
Reports are available to review prior authorization data for each ACA Marketplace plan on the Federal Marketplace Exchange.
This data is being reported consistent with the CMS Interoperability and Prior Authorization Final Rule and includes certain prior authorization and appeal information for members enrolled in UnitedHealthcare Individual & Family ACA Marketplace plans on the Federal Marketplace Exchange from January 1, 2025 to December 31, 2025, including prior authorization requests for transitions to post-acute care and requests submitted to capitated-delegated providers, behavioral health delegates, physical health delegates and dental delegates (where applicable). The reports do not include any reporting related to prescription drugs (not under the medical benefit). Data for non-integrated entities will be reported separately. Information is current as of the date of posting.