Service Authorization Metrics
Review the Virginia Medicaid Prior Authorization Metrics for medical items and services (excluding drugs).
Annual Prior Authorization Summary
To meet the CMS Interoperability and Prior Authorization final rule, the Anthem HealthKeepers Plus plan must post a yearly summary on our website that shows how we handle prior approval requests for medical care. This includes a list of all medical services and supplies (not including drugs) that need approval before use, along with data showing how many requests were approved or denied in the past year. Sharing this information helps keep things clear and honest.
For questions on the data below, members and providers can contact HealthKeepers, Inc. at 800-901-0020 (TTY 711).
Review the medical supplies and services that need prior authorization (not including drugs).
Before January 1, 2026, Medicaid Managed Care Plans must give prior approval decisions within these time limits:
- 72 hours for expedited (urgent) requests
- 14 calendar days for standard (non-urgent) requests
Starting January 1, 2026, new federal rules from CMS will require Medicaid Managed Care Plans to give prior approval decisions within these time limits:
- 72 hours for expedited (urgent) requests
- 7 calendar days for standard (non-urgent) requests
Annual Reporting Metrics
Data reported are current decisions as of 12/31 of the reporting calendar year.
Reporting Year: 2026
Standard Prior Authorization (PA) Request Summary
Initial Outcome
|
2026 Decisions |
Total Occurrences |
|---|---|
|
Standard Prior Authorizations |
83,309 |
|
Expedited Prior Authorizations |
17,003 |
2026 Decisions |
|---|
|
Standard Prior Authorizations |
|
Expedited Prior Authorizations |
Total Occurrences |
|---|
|
83,309 |
|
17,003 |
Standard Review
|
Decision |
Decision Occurrences |
Outcome (%) |
|---|---|---|
|
Approved |
72,719 |
87.29% |
|
Denied |
10,590 |
12.71% |
Decision |
|---|
|
Approved |
|
Denied |
Decision Occurrences |
|---|
|
72,719 |
|
10,590 |
Outcome (%) |
|---|
|
87.29% |
|
12.71% |
Expedited Prior Authorization (PA) Request Summary
Urgent 72-hour Response
|
Decisions |
Decision Occurrences |
Outcome (%) |
|---|---|---|
|
Approved |
15,490 |
91.10% |
|
Denied |
1,513 |
8.90% |
Decisions |
|---|
|
Approved |
|
Denied |
Decision Occurrences |
|---|
|
15,490 |
|
1,513 |
Outcome (%) |
|---|
|
91.10% |
|
8.90% |
Extended Review
|
Decision |
Decision Occurrences |
Outcome (%) |
|---|---|---|
|
Approved |
335 |
0.33% |
Decision |
|---|
|
Approved |
Decision Occurrences |
|---|
|
335 |
Outcome (%) |
|---|
|
0.33% |
Prior Authorization Request and Decision Timeframe Summary
|
Decision Timeframe |
Mean (Average) Time |
Median (Middle) Time |
|---|---|---|
|
Standard Request (Days) |
2.7 |
0.0 |
|
Expedited Request (Hours) |
26.6 |
18.0 |
Decision Timeframe |
|---|
|
Standard Request (Days) |
|
Expedited Request (Hours) |
Mean (Average) Time |
|---|
|
2.7 |
|
26.6 |
Median (Middle) Time |
|---|
|
0.0 |
|
18.0 |