Prior authorization metrics for medical items and services (excluding drugs)

To comply with the CMS Interoperability and Prior Authorization final rule, Capital Blue Cross is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers. For questions on the data below, call the Member Services number on the back of your ID card.

Reporting period: 2025

These are the medical items and services for which we require prior authorization (excluding drugs).

Please refer to our single source preauthorization list.

Prior to January 1, 2026, impacted payers were required to send prior authorization decisions for Medicare Advantage (MA) plans within:

• 72 hours for expedited requests (urgent).
• 14 calendar days for standard requests (non-urgent).

Beginning January 1, 2026, the CMS Interoperability and Prior Authorization final rule requires MA plans to send prior authorization decisions within:

• 72 hours for expedited requests (urgent).
• Seven calendar days for standard requests (non-urgent).

Standard (non-urgent) Prior Authorization Requests

Expedited (urgent) Prior Authorization Requests (Responses Due to Provider Within 72 Hours)

Results based on limited data should be interpreted with caution. Outcomes are expected to stabilize as more data becomes available.