Prior Authorization Metrics For Medical Items and Services (Excluding Drugs)
To comply with the CMS Interoperability and Prior Authorization final rule, VillageCareMAX 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 over the previous calendar year.
Reporting Period: 2025
Prior Authorization Information
Click Here for a list of all items and services that require prior authorization (excluding drugs)
VillageCareMAX Medicare Plans
All items and services are aggregated and reported for all VillageCareMAX Medicare plans, including:
- VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP)
- VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP)
- VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP)
- VillageCareMAX Medicare Select Advantage Plan (HMO)
Standard (non-urgent) Prior Authorization Requests | |
Public Reporting Measure | Percentage |
| Request Approved | 82.2% |
| Request Denied | 17.8% |
| Request approved after appeal | 32.9% |
| Request approved after time for review was extended | 48.0% |
Expedited (urgent) Prior Authorization Requests | |
Public Reporting Measure | Percentage |
| Request Approved | 96.5% |
| Request Denied | 3.5% |
| Request approved after time for review was extended | 83.3% |
Time Between Receiving a Prior Authorization Request and Sending a Decision | ||
Public Reporting Measure | Mean (Average) Timeframe | Median (Middle) Timeframe |
| Standard (non-urgent) Prior Authorization Requests | 6.53 Days | 5.00 Days |
| Expedited (urgent) Prior Authorization Requests | 0.74 Days | 0.00 Days |
VillageCareMAX Medicare Total Advantage Plan (HMO DSNP)
Medicaid Prior Authorization Requests
Standard (non-urgent) Prior Authorization Requests | |
Public Reporting Measure | Percentage |
| Request Approved | 71.4% |
| Request Denied | 28.6% |
| Request approved after appeal | 13.5% |
| Request approved after time for review was extended | 24.8% |
Expedited (urgent) Prior Authorization Requests | |
Public Reporting Measure | Percentage |
| Request Approved | 84.3% |
| Request Denied | 15.7% |
| Request approved after time for review was extended | 22.2% |
Time Between Receiving a Prior Authorization Request and Sending a Decision | ||
Public Reporting Measure | Mean (Average) Timeframe | Median (Middle) Timeframe |
| Standard (non-urgent) Prior Authorization Requests | 4.84 Days | 3.00 Days |
| Expedited (urgent) Prior Authorization Requests | .87 Days | 0.00 Days |
VillageCareMAX MLTC Managed Long-Term Care Plan
Prior Authorization Requests
Standard (non-urgent) Prior Authorization Requests | |
Public Reporting Measure | Percentage |
| Request Approved | 37.7% |
| Request Denied | 62.3% |
| Request approved after appeal | 4.3% |
| Request approved after time for review was extended | 33.3% |
Expedited (urgent) Prior Authorization Requests | |
Public Reporting Measure | Percentage |
| Request Approved | 53.4% |
| Request Denied | 46.6% |
| Request approved after time for review was extended | 46.8% |
Time Between Receiving a Prior Authorization Request and Sending a Decision | ||
Public Reporting Measure | Mean (Average) Timeframe | Median (Middle) Timeframe |
| Standard (non-urgent) Prior Authorization Requests | 7.28 Days | 5.00 Days |
| Expedited (urgent) Prior Authorization Requests | 3.86 Days | 1.00 Days |
