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Centene — Denial Rates & Appeal Data

Name: Centene prior authorization denial metrics
Creator: Coverage Rights

Medicare AdvantageMedicaid MCOMarketplace QHPReporting year 2025

Compare against every insurer we track: denial rates ranked within reporting cohorts.

Prior-auth denial rate

9.8%

of Medicare Advantage, Medicaid, and Marketplace contracts requests denied

Appeal overturn rate

69%

of appealed Medicare Advantage, Medicaid, and Marketplace contracts denials reversed

PA requests

7.4M

reported within the published scope for 2025

COVERAGE RIGHTS ROLLUP · CALCULATED FROM CENTENE PUBLIC DISCLOSURES

Rollup computed from Centene's own posted per-contract CMS-0057-F reports with full request counts (44 contracts across the Wellcare, Health Net, and Ambetter brands: 27 Medicare Advantage, 3 Medicaid plans incl. Health Net Medi-Cal, 14 marketplace issuers). Combined standard+expedited basis. By line: Medicare Advantage 12.4%, Medicaid 2.9%, marketplace (Ambetter) 24.7% standard denial. 69.0% of 40,160 reported appeals were overturned. Per-contract source links appear in the table below.

UNDERLYING SOURCE: CENTENE CMS-0057-F DISCLOSURE, CY2025 · VIEW SOURCE ↗ · METHODOLOGY

Metrics by contract / plan

Centene’s own CY2025 CMS-0057-F disclosures, plan by plan. Standard-request figures; every row links to its source.

Centene CY2025 prior authorization metrics by contract or plan
Contract / plan	Line	Requests	Denied	Appeals overturned	Avg decision	Source
CA-SHP · CA Health Net	Medicaid	3,096,168	2.45%	39.72%	2d	Source
49004 · FL Ambetter	Marketplace	419,452	21%	58.23%	4d	Source
CA-CalViva · CA Health Net	Medicaid	310,319	6.34%	48.28%	3d	Source
H3561 · CA Health Net	Medicare Advantage	290,257	1.98%	77.5%	3d	Source
29418 · TX Ambetter	Marketplace	218,062	32.94%	61.91%	2d	Source
H0174 · TX Wellcare	Medicare Advantage	192,173	19.3%	94.76%	5d	Source
H0562 · CA Health Net	Medicare Advantage	184,541	1.94%	77.17%	3d	Source
H1032 · FL Wellcare	Medicare Advantage	171,190	19.54%	84.38%	3d	Source
H2775 · NY Wellcare	Medicare Advantage	151,140	16.46%	94.24%	4d	Source
H5087 · CA Wellcare	Medicare Advantage	120,425	2.8%	62.79%	2d	Source
H1416 · IL,MS,AR,TN,SC Wellcare	Medicare Advantage	106,623	16.19%	94.97%	4d	Source
70111 · TN Ambetter	Marketplace	104,566	22.76%	68.5%	2d	Source
79222 · SC Ambetter	Marketplace	99,318	21.46%	56.8%	4d	Source
90714 · MS Ambetter	Marketplace	91,950	21.52%	33.84%	2d	Source
H4506 · TX Wellcare	Medicare Advantage	90,924	13.23%	96.74%	5d	Source
H4868 · NY Wellcare	Medicare Advantage	90,696	20.84%	92.72%	4d	Source
99723 · MO Ambetter	Marketplace	89,747	22.81%	57.57%	2d	Source
87226 · TX Ambetter	Marketplace	89,666	32.48%	60.06%	2d	Source
H9730 · KY Wellcare	Medicare Advantage	86,206	19.61%	97.7%	3d	Source
34368 · KS Ambetter	Marketplace	64,114	25.52%	52.35%	5d	Source
CA-ImperialValley · CA Health Net	Medicaid	57,406	7.57%	48.05%	3d	Source
35065 · IN Ambetter	Marketplace	56,928	24.58%	36.31%	2d	Source
91450 · AZ Ambetter	Marketplace	54,027	25.99%	37.3%	4d	Source
41047 · OH Ambetter	Marketplace	52,991	28.38%	56.92%	4d	Source
H1112 · GA Wellcare	Medicare Advantage	52,573	15.31%	94.19%	4d	Source
77264 · NC Ambetter	Marketplace	50,371	20.68%	51.82%	2d	Source
H0913 · NJ Wellcare	Medicare Advantage	42,739	17.51%	96.51%	5d	Source
H7326 · SC Wellcare	Medicare Advantage	32,752	14.59%	97.82%	4d	Source
H2491 · LA Wellcare	Medicare Advantage	27,851	13.5%	96.49%	4d	Source
H5965 · WA Wellcare	Medicare Advantage	26,621	18.46%	97.58%	5d	Source
H0029 · WA Wellcare	Medicare Advantage	26,108	16.5%	96.37%	5d	Source
90787 · LA Ambetter	Marketplace	22,862	24.25%	30.59%	3d	Source
H5779 · IL Wellcare	Medicare Advantage	14,880	16.63%	95.14%	4d	Source
H7323 · TX Wellcare	Medicare Advantage	14,095	19.21%	98.57%	4d	Source
H4847 · SC Wellcare	Medicare Advantage	13,731	14.75%	95.74%	4d	Source
H1914 · NC Wellcare	Medicare Advantage	13,552	14.73%	98.67%	4d	Source
H0111 · GA Wellcare	Medicare Advantage	12,773	15.66%	94.26%	4d	Source
H3975 · KY Wellcare	Medicare Advantage	9,461	20.39%	97.08%	3d	Source
H4073 · NC Wellcare	Medicare Advantage	8,937	13.56%	100%	4d	Source
86382 · FL Ambetter	Marketplace	6,402	18.28%	64.15%	4d	Source
H7518 · MO Wellcare	Medicare Advantage	3,480	14.8%	94.74%	4d	Source
H0074 · MS Wellcare	Medicare Advantage	3,134	16.94%	100%	4d	Source
H2816 · NY Wellcare	Medicare Advantage	1,635	10.34%	90%	4d	Source
H0270 · AR Wellcare	Medicare Advantage	850	15.88%	93.75%	4d	Source

N/R = NOT REPORTED · COLLECTED 2026-07-19 FROM CENTENE’S PUBLISHED DISCLOSURES

What these numbers mean for your denial

Coverage Rights calculated a 9.8% prior-authorization denial rate for the Medicare Advantage, Medicaid, and Marketplace contracts in 2025. In the calculated Medicare Advantage, Medicaid, and Marketplace contracts appeal scope, 69% were reversed — most denials that got challenged did not survive review. The underlying contract or plan figures were published by Centene; Coverage Rights performed the stated rollup.

The practical takeaway is narrower: an initial denial can change on review. These aggregate rates describe past decisions within the stated reporting scope; they do not predict the result of an individual appeal.

Your appeal deadline depends on your plan type

Centene runs several kinds of plans, and the appeal rules follow the plan, not the insurer. Find the ladder and the deadlines for yours:

Medicare Advantage appeal rights Medicaid appeal rights ACA / Marketplace appeal rights

Common questions

What is Centene's prior authorization denial rate?

Coverage Rights calculated a 9.8% prior-authorization denial rate for the Medicare Advantage, Medicaid, and Marketplace contracts reporting scope in 2025, using the public disclosure required by federal rule CMS-0057-F. Within the calculated Medicare Advantage, Medicaid, and Marketplace contracts appeal scope, 69% were overturned.

How do I appeal a Centene denial?

Start with the appeal instructions in Centene's denial notice. An independent external, fair-hearing, or Medicare review may be available after the required internal review, but eligibility depends on the coverage program, plan funding, denial type, regulating jurisdiction, and whether the notice says internal review is exhausted. Use the pathway tool before choosing the next reviewer.

Where do these numbers come from?

Coverage Rights calculated the displayed rollup from Centene's public CMS-0057-F disclosures for 2025. The methodology note identifies the included reporting scope and weighting or aggregation method; source links lead to the underlying insurer-published records.

Denied by Centene? 69% were overturned in the Coverage Rights rollup of the Medicare Advantage, Medicaid, and Marketplace contracts scope. Build an evidence-backed appeal.

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