OB/GYN Denial Rates by Payer: What CAQH Index Data Tells Us About Prior Auth Friction

Reviora Healthcare LLC | Guaranteed Revenue Partner

Your team can file a flawless prior authorization and still lose it, because the payer on the other end sets the odds. Every denial you don’t catch becomes unpaid staff hours, delayed procedures, and revenue you never see. The published data shows how wide those odds swing, and where the data stops.

The short answer: denial risk is set payer by payer, not practice-wide, so measure each payer and appeal what you can win. Three facts support that. Prior auth is still largely manual work, payer denial rates differ several-fold, and most Medicare Advantage denials are never appealed.

Does the CAQH Index show OB/GYN denial rates by payer?

No. The public CAQH Index Executive Report, a nonprofit benchmark of healthcare administrative automation, tracks how transactions like prior authorization move, not denial rates by payer or specialty.

What it shows is friction. Fully electronic adoption for medical prior authorization reached 40% in the 2025 Index, up from 31% in 2023. The 2024 Index estimated that full electronic exchange would save providers about 14 minutes per authorization and the industry $515 million a year.

Physicians confirm the manual reality. In the American Medical Association’s (AMA) 2025 survey of 1,000 physicians, the phone was the most common way to complete prior authorizations for medical services.

How much do denial rates differ by payer?

Several-fold. KFF’s 2026 analysis of payers’ first public prior authorization reports (2025 data) found standard requests denied 12% of the time in Medicare Advantage, 14% in Medicaid managed care, and 18% on ACA Marketplace plans.

Individual insurers diverge more. Among large Medicare Advantage insurers, denials ran from 5% (Elevance) to 17% (UnitedHealth Group). On the Marketplace, they ran from 3% (GuideWell) to 25% (Centene). One insurer can also differ by line of business: UnitedHealth denied 17% of standard requests in Medicare Advantage, 11% in Medicaid managed care, and 21% on the Marketplace.

One caution: these rates are aggregated across all medical services. None isolate OB/GYN, so treat them as payer-behavior signals, not OB/GYN benchmarks.

How much of that loss can a practice win back?

A lot, because few denials are challenged. Only 11.5% of denied Medicare Advantage prior authorization requests were appealed in 2024 (KFF, 2026). Yet insurers overturned 67% of appealed standard denials in Medicare Advantage, 47% in Medicaid managed care, and 43% on the Marketplace in 2025. KFF notes that a high overturn rate can signal a first request that lacked required documentation.

The staff cost is just as real. The AMA’s 2025 survey found prior authorization takes an average of 13 hours of physician and staff time each week, 40% of physicians employ staff dedicated solely to it, and 74% report denials have increased over five years.

What should an OB/GYN practice do first?

Build a payer scorecard from your own data, because your numbers beat national averages. Three moves:

1. Pull each payer’s posted prior authorization list and metrics. KFF reports the CMS rule requires Medicare Advantage, Medicaid, and HealthCare.gov plans to publish both.
2. Track four numbers per payer and line of business: denial rate, appeal rate, appeal win rate, and days to decision.
3. Hold payers to the clock and the reason. CMS’s rule sets 72-hour (expedited) and 7-calendar-day (standard) decision limits for impacted payers, excluding HealthCare.gov issuers, and requires denial reasons beginning in 2026.

At Reviora, human specialists lead and technology supports. We call that Expert-Led Technology. Our Claims & Denials team works payer by payer, and our OB/GYN RCM approach is built around payer-level tracking. Our Managed Outcome Agreement (MOA) is a written contractual performance agreement built on five benchmarks. A Benchmark Recovery Protocol (BRP) activates after two consecutive missed months. See The Reviora Guarantee or browse all Services.

Want to see where your payers stand? Book a 30-minute consult or visit Get Started.

FAQ

What is the average prior authorization denial rate?
It depends on the market. In 2025, standard requests were denied 12% in Medicare Advantage, 14% in Medicaid managed care, and 18% on ACA Marketplace plans, with large insurers ranging from 2% to 25% across the three markets (KFF, 2026).

What does the CAQH Index measure?
It measures adoption, volume, cost, and time for administrative transactions such as eligibility checks, prior authorization, and claims. The public Executive Report doesn’t report denial rates.

How long does a payer have to respond to a prior authorization request?
Under CMS’s rule, impacted payers, excluding HealthCare.gov issuers, must decide expedited requests within 72 hours and standard requests within seven calendar days. KFF reports Marketplace plans still had 15 days for standard requests in 2025.

Do prior authorization denials get overturned on appeal?
Often, when they are appealed. In 2025, 67% of appealed standard denials were overturned in Medicare Advantage, 47% in Medicaid managed care, and 43% on the Marketplace.

Reference

1. CAQH. 2025 CAQH Index Report: Executive Report. 2025. https://index.caqh.org/hubfs/Index/CAQH_IndexReport_2025_Executive%20Report_v6.pdf
2. CAQH. 2024 CAQH Index Report: Key Takeaways. 2024. https://caqh.org/hubfs/Index/2024%20Index%20Report/CAQH%202024%20Index%20Report%20Key%20Takeaways%20FINAL.pdf
3. KFF. Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain. Aug 13, 2026. https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/
4. KFF. Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024. Jan 28, 2026. https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/
5. AMA (Tanya Albert Henry). Only 1 in 3 doctors trusts insurers’ prior authorization promises (reporting the 2025 AMA Prior Authorization Physician Survey, n=1,000, fielded Dec 2025). May 18, 2026. https://www.ama-assn.org/practice-management/prior-authorization/only-1-3-doctors-trusts-insurers-prior-authorization
6. CMS. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Fact Sheet. Jan 17, 2024. https://www.cms.gov/files/document/fact-sheet-cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.pdf