CurrentSelectHealthPolicy N/A

Colorado Statistics for Select Health Commercial Plans Prior Authorization Case Review

Quarterly disclosure of prior authorization requests and outcomes for SelectHealth commercial fully insured plans in Colorado, reporting counts of approvals, denials (by reason), and denials overturned on appeal, broken down by procedure/service categories and provider types for Q1 2024.

Policy Summary

PayerSelectHealth

PolicyColorado Statistics for Select Health Commercial Plans Prior Authorization Case Review

Policy CodePolicy N/A

Change TypeInformational disclosure (no material change)

Effective Date

Next Review Date

Key ActionReview the disclosed Q1 2024 prior authorization counts and outcomes for SelectHealth commercial fully insured plans in Colorado to ensure compliance with Colorado Statute 10-16-124.5.

SourceLink

POLICY UPDATE CHANGES

No material changes

336Grand Total Approved

238Grand Total Denied

83Denied - Not Medically Necessary

155Denied - Lack of Information/Other

Q1 2024 Prior Authorization Disclosure — SelectHealth (Colorado, Fully Insured Commercial)

This report is published to satisfy Colorado Statute 10-16-124.5, which requires disclosure of prior authorization approvals, denials, and denials overturned on appeal for commercial fully insured plans.

It covers SelectHealth commercial fully insured plans in Colorado for Q1 2024 and enumerates counts included in the disclosure: total approvals and denials, denials by reason (e.g., Not Medically Necessary and Lack of Information/Other), denials overturned on appeal, and breakdowns by procedure/service category (for example, Pharmacy, Durable Medical Equipment, OP Facility - Surgery) and by provider type (for example, Primary Care Provider, Specialist).

Prior Authorization Counts (headline metrics)

The stats_bar above shows the primary headline counts for prior authorization outcomes. The following section provides the full set of reported metrics and supporting breakdowns by service category and provider type as disclosed for Q1 2024.

Key Definitions

Prior authorization: The process by which a carrier or organization determines the medical necessity and appropriateness of otherwise covered health care services prior to the rendering of the services, including preadmission review, pretreatment review, utilization review, and case management.

Reporting Scope and Breakdown

This disclosure is a quarterly report of prior authorization requests and outcomes for SelectHealth commercial fully insured plans in Colorado for Q1 2024.

Counts are reported for approvals, denials (with reason categories such as Not Medically Necessary and Lack of Information/Other), and denials overturned on appeal.

Reported counts are broken down by procedure/service categories (for example, Pharmacy, Durable Medical Equipment (DME), Home Health, OP Facility - Surgery) and by provider types (for example, Primary Care Provider (PCP) and Specialist (SCP)), with the detailed case counts shown in the tabulated data.

Service Category Highlights

Provider Type Highlights

Implications for Providers

Note

Informational disclosure — not a coverage policy

This document is a statistical disclosure provided to comply with Colorado Statute 10-16-124.5 and summarizes prior authorization request counts and outcomes for SelectHealth commercial fully insured plans in Colorado for Q1 2024. It is informational only and is not a clinical coverage policy. It does not change existing prior authorization requirements or operational PA processes.

Documentation Required

Keep documentation for potential appeals

Retain sufficient clinical documentation to support appeals, as this report shows some denials were overturned on appeal. The Q1 2024 statistics show 13 denied prior authorizations were overturned on appeal.

Include clear clinical rationale and indication for the requested service
Attach relevant test results, imaging, and consult notes
Document prior treatments, responses, and therapy durations

Statutory and Reporting Background

State law requires publication of prior authorization approvals, denials, and overturned denials to increase transparency for services that require prior authorization for fully insured commercial plans.

This report fulfills that statutory requirement under Colorado Statute 10-16-124.5 for the reporting period Q1 2024.

Document Revision History

statusLatest

Document status: CURRENT. No dated revision entries were provided in the brief; revision history events were not included.