To comply with the CMS Interoperability and Prior Authorization final rule, Sentara Health Plans 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, contact us.
A list of medical items and services for which we require prior authorization (excluding drugs) can be found here: https://pal.sentarahealthplans.com/.
Prior to January 1, 2026, Sentara Health Plans was required to send prior authorization decisions within the following timeframes:
- 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 Sentara Health Plans to send prior authorization decisions within:
- 72 hours for expedited requests (urgent)
- 7 calendar days for standard requests (non-urgent)
Medicaid
Reporting Period: January 1, 2025 – December 31, 2025
(*Data reported is current as of 1/30/2026)
Total standard authorization request decisions: 228,807
Total expedited authorization request decisions: 121,645
| Decision Type | Occurrence | Total Requests | Percentage |
| Decision Type Standard authorization request approved | Occurrence 183,059 | Total Requests228,807 | Percentage80.01% |
| Decision Type Standard authorization request denied | Occurrence 45,748 | Total Requests228,807 | Percentage19.99% |
| Decision Type Standard authorization request approved after appeal review | Occurrence 443 | Total Requests 1,363 | Percentage 32.50% |
| Decision Type Expedited authorization request approved | Occurrence 105,748 | Total Requests121,645 | Percentage86.93% |
| Decision Type Expedited authorization request denied | Occurrence 15,897 | Total Requests121,645 | Percentage13.07% |
| Decision TypeStandard and expedited authorizations approved following extended review | Occurrence 0 | Total Requests350,452 | Percentage0.00% |
| Authorization turnaround time | Mean (average) time | Median (middle) time |
| Authorization turnaround time Standard authorization turnaround time | Mean (average) time 6.4 days | Median (middle) time 5.0 days |
| Authorization turnaround time Expedited authorization turnaround time | Mean (average) time 26.2 hours | Median (middle) time 22.4 hours |
Commercial
| Decision Type | Decision Occurrences | Total Standard PA Decisions | Percentage of Standard PA Decisions |
| Decision TypeStandard authorization request approved | Decision Occurrences108,452 | Total Standard PA Decisions120,290 | Percentage of Standard PA Decisions90.16% |
| Decision TypeStandard authorization request denied | Decision Occurrences11,838 | Total Standard PA Decisions120,290 | Percentage of Standard PA Decisions9.84% |
| Decision TypeExpedited request approved | Decision Occurrences16,169 | Total Standard PA Decisions16,746 | Percentage of Standard PA Decisions96.55% |
| Decision TypeExpedited request denied | Decision Occurrences577 | Total Standard PA Decisions16,746 | Percentage of Standard PA Decisions3.45% |
| Decision TypeRequest approved following extended review | Decision Occurrences0 | Total Standard PA Decisions137,036 | Percentage of Standard PA Decisions0.00% |
| Decision TypeStandard request approved following appeal review | Decision Occurrences56 | Total Standard PA Decisions127 | Percentage of Standard PA Decisions44.09% |
| PA Turnaround time | Mean (average) TAT | Median (middle) TAT |
| PA Turnaround timeStandard PA Request TAT | Mean (average) TAT4.0 days | Median (middle) TAT2.0 days |
| PA Turnaround timeExpedited PA Request TAT | Mean (average) TAT20.1 hours | Median (middle) TAT1.0 hours |
Medicare
| Decision Type | Decision Occurrences | Total Standard PA Decisions | Percentage of Standard PA Decisions |
| Decision TypeStandard authorization request approved | Decision Occurrences46,995 | Total Standard PA Decisions49,506 | Percentage of Standard PA Decisions94.93% |
| Decision TypeStandard authorization request denied | Decision Occurrences2,511 | Total Standard PA Decisions49,506 | Percentage of Standard PA Decisions5.07% |
| Decision TypeExpedited request approved | Decision Occurrences5,371 | Total Standard PA Decisions5,527 | Percentage of Standard PA Decisions97.18% |
| Decision TypeExpedited request denied | Decision Occurrences156 | Total Standard PA Decisions5,527 | Percentage of Standard PA Decisions2.82% |
| Decision TypeRequest approved following extended review | Decision Occurrences0 | Total Standard PA Decisions55,033 | Percentage of Standard PA Decisions0.00% |
| Decision TypeStandard request approved following appeal review | Decision Occurrences134 | Total Standard PA Decisions127 | Percentage of Standard PA Decisions0% |
| PA Turnaround time | Mean (average) TAT | Median (middle) TAT |
| PA Turnaround timeStandard PA Request TAT | Mean (average) TAT4.8 days | Median (middle) TAT2.0 days |
| PA Turnaround timeExpedited PA Request TAT | Mean (average) TAT22.0 hours | Median (middle) TAT4.0 hours |