Highmark — Denial Rates & Appeal Data
Compare against every insurer we track: denial rates ranked within reporting cohorts.
COVERAGE RIGHTS ROLLUP · CALCULATED FROM HIGHMARK PUBLIC DISCLOSURES
Rollup computed from Highmark's enterprise per-contract report where request counts are posted (12 of 14 reporting units: 8 Medicare Advantage contracts plus state Medicaid and marketplace units; 2 percentage-only units excluded). Combined standard+expedited basis (4.2% standard, 7.2% expedited). Appeal counts are not published at the enterprise level, so no overturn rate is derivable.
UNDERLYING SOURCE: HIGHMARK CMS-0057-F DISCLOSURE, CY2025 · VIEW SOURCE ↗ · METHODOLOGY
Metrics by contract / plan
| Contract / plan | Line | Requests | Denied | Appeals overturned | Avg decision | Source |
|---|---|---|---|---|---|---|
| H3916 | Medicare Advantage | 463,352 | 4% | n/r | n/r | |
| qhp-issuer-level | Marketplace | 120,652 | 8% | n/r | n/r | |
| H3957 | Medicare Advantage | 98,307 | 3% | n/r | n/r | |
| H5106 | Medicare Advantage | 41,018 | 5% | n/r | n/r | |
| H3384 | Medicare Advantage | 39,409 | 1% | n/r | n/r | |
| medicaid-ffs-DE · DE | Medicaid | 32,291 | 1% | n/r | 3.8d | |
| H8166 | Medicare Advantage | 27,105 | 4% | n/r | n/r | |
| H5526 | Medicare Advantage | 25,925 | 1% | n/r | n/r | |
| medicaid-ffs-PA · PA | Medicaid | 22,141 | 4% | n/r | 1.48d | |
| H5932 · PA | Medicare Advantage | 7,010 | 12% | n/r | 4.74d | |
| medicaid-ffs-WV · WV | Medicaid | 1,426 | 4% | n/r | n/r | |
| H7710 · DE | Medicare Advantage | 671 | 12% | n/r | 4.8d | |
| medicaid-ffs-NY · NY | Medicaid | n/r | 8.7% | n/r | 2d | |
| medicaid-mco-plan-level | Medicaid MCO | n/r | 2% | n/r | 2.07d |
Your appeal deadline depends on your plan type
Highmark runs several kinds of plans, and the appeal rules follow the plan, not the insurer. Find the ladder and the deadlines for yours:
Common questions
What is Highmark's prior authorization denial rate?
Coverage Rights calculated a 4.8% prior-authorization denial rate for the Medicare Advantage, Medicaid, and Marketplace reporting units reporting scope in 2025, using the public disclosure required by federal rule CMS-0057-F.
How do I appeal a Highmark denial?
Start with the appeal instructions in Highmark'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 Highmark'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.