Research & Resources, OneAnother Health

Prior Authorization
Transparency Inventory

A structured inventory of public-facing utilization management and prior authorization performance data across major payers, PBMs, employer plans, BCBS independent plans, and state regulatory models. Updated as new data is published.

Prior authorization transparency data is fragmented, incomplete, and operationally opaque. CMS-0057-F created the first federal mandate for payer PA metric disclosure, but it excludes pharmacy, omits denial reasons, has no service-level breakdown requirement, and does not reach the roughly 60 percent of privately insured Americans covered under ERISA self-insured employer plans. No major PBM publishes pharmacy PA performance data voluntarily. This inventory documents what is publicly available, who is required to report, where the data falls short, and what the emerging state and federal regulatory landscape looks like through April 2026.

CMS-0057-F (CY2025 data, reported March 2026) · AHIP/BCBSA voluntary commitments · State mandates

● Last Updated:

U.S. Privately Insured Population: PA Transparency by Coverage Segment
60%
10%
6%
8%
10%
6%
ERISA Self-Insured (60%) DARK ZONE
~158M Americans. No reporting pathway. ERISA preempts all state mandates.
Fully Insured , Active Enforcement (10%)
~26M Americans. Aggregated state data only. No group-specific PA data available.
Fully Insured , Variable Enforcement (6%) ENFORCEMENT GAP
~16M Americans. UM statutes exist; enforcement quality varies significantly by domicile.
Medicare Advantage (8%)
~21M Americans. CMS-0057-F compliant. Medical PA only, no pharmacy.
Medicaid MCO (10%)
~26M Americans. CMS-0057-F compliant. Medical PA only, no pharmacy.
FFS / Other (6%)
~16M Americans. Minimal or no PA transparency.
Source: KFF Employer Health Benefits Survey 2024 · CMS Enrollment Data 2025 · Estimates approximate. Fully insured enforcement split is illustrative.
Current data limitations: CMS-0057-F metrics are aggregated across all services, no service-level or drug-class breakdown required. Pharmacy/drug PA is excluded from the 2024 final rule; addressed only in proposed CMS-0062-P (published April 14, 2026, comments due June 15, 2026; compliance proposed October 2027). Beginning January 2026, impacted payers must provide specific denial reasons to providers on individual MA, Medicaid MCO, CHIP, and QHP PA decisions per CMS-0057-F. This is an operational provider-facing requirement; it does not require aggregate denial reasons in public reporting, which is what this inventory captures. Drug PA decisions and ERISA self-insured plans are excluded from both. Fully insured employer groups receive no group-specific PA data under any mechanism.
Column key: ✓ Reported|✕ Not reported
The Four-Layer Transparency Gap
1
ERISA Self-Insured Plans
No reporting pathway. ~158M Americans invisible. ERISA Section 514 preempts every state remedy. No federal rule currently reaches this population.
2
Fully Insured Employer Groups
Regulated product, but no group-specific data. Renewal and contracting decisions made without PA performance evidence. Domicile state enforcement quality determines whether even aggregated protections are real.
3
PBM Pharmacy PA
Every major PBM publishes zero pharmacy PA metrics. CMS-0062-P proposed; pharmacy data earliest 2028 for regulated payers , not standalone PBMs, not ERISA plans.
4
Medical PA Aggregation
Even where CMS-0057-F data exists, no service-level breakdown and no denial reasons are required , making the numbers analytically inert for clinical, fiduciary, or contracting purposes.
CMS.gov · KFF.org · AHIP.org
Payer websites · MA DOI · WA OIC
State Regulators ·
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