Prior authorization made clear:
98.9% of Medicaid plan medical claims do not require prior authorization1
For Medicaid and Children’s Health Insurance Program (CHIP) plans, only 1.1% 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. State Medicaid agencies set the rules for Medicaid coverage, including which treatments and services require prior authorization.
Prior authorization by the numbers
98.9%
of medical claims did not need prior authorization1
Only a fraction of medical claims require prior authorization
91.5%
of prior authorizations were approved2
9 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 Medicaid and CHIP plans
You may have some questions about the prior authorization process. Review these answers to learn more.
UnitedHealthcare Community Plan administers the benefits set by state Medicaid agencies and follows the state’s requirements. This includes any state-specific rules about when prior authorization is needed. Nearly half of all prior authorizations are approved in real-time and almost all decisions are made within 24 hours.4
Requirements can vary by state and plan, so prior authorization may be required in one state or setting, but not another.
Because Medicaid programs and clinical guidance evolve, prior authorization requirements may be updated over time. We follow applicable state and federal requirements, including mental health parity rules, when we implement those changes.
View Medicaid prior authorization data
Reports are available to review prior authorization data for each Medicaid and CHIP plan.
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 Medicaid and CHIP plans 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.