Know Your Rights
Your Insurance Company Must Now Report How Often They Deny You
A new federal rule (CMS-0057-F) is forcing every major insurer to publicly report their prior authorization denial rates — starting March 2026. Here's what that means for you.
What's changing
March 31, 2026
Insurers must publicly report how often they approve and deny prior authorizations, broken down by category. First reports due to CMS.
January 1, 2027
Insurers must implement electronic Prior Authorization APIs — meaning faster decisions, real-time status updates, and specific denial reasons delivered electronically.
What this means for you
For the first time, you'll be able to see which insurers deny the most — and Ellen will help you decode the data, know your options, and fight back when denials aren't justified.
What the data already shows
Prior authorizations submitted to Medicare Advantage plans annually
Average PA denial rate — but some plans deny at 2-3x that rate
Of denied PAs are never appealed by the patient
Of appealed PA denials are overturned — meaning the denial was wrong
Your rights as a patient
You have the right to appeal every denial
Insurers count on the fact that 82% of patients never appeal. But nearly half of all appeals succeed. If your medication was denied, that's not the end — it's the beginning.
You have the right to a specific reason
Under the new rule, insurers must provide a specific, coded reason for every denial — not just 'medical necessity.' This makes it easier to target your appeal to the actual objection.
You have the right to an expedited review
If your health is at risk, you can request an expedited (urgent) appeal. Insurers must respond within 72 hours for standard appeals and 24 hours for expedited.
You have the right to an external review
If your internal appeal is denied, you can request an Independent Review Organization (IRO) — a neutral third party reviews your case. Insurers cannot refuse this.
Your doctor is your best advocate
A peer-to-peer call between your prescribing doctor and the insurer's medical director is often the fastest path to overturning a denial. Ask your doctor's office to request one.
State-specific PA protections
Beyond federal rules, 14+ states have passed their own PA reform laws — including gold carding programs, step therapy overrides, continuity of care protections, and faster decision timelines.
Find your state's PA protections →Already treated but now denied?
Retroactive denials happen when your insurer refuses to pay afteryou've already received treatment. You have rights — and steps you can take to fight back.
Learn what to do →Biosimilar switches — the new PA battleground
In 2025-2026, dozens of biosimilars are launching for major drugs like Stelara, Humira, and Eylea. Insurers are moving fast to switch patients to lower-cost alternatives. While biosimilars are safe and effective, non-medical switching— forcing a switch when you're stable on your current medication — is something you can fight.
Ellen decodes what they don't want you to understand
Prior authorization is designed to be confusing. Ellen translates denial codes, maps step therapy ladders, finds clinical shortcuts, and generates appeals — all in simple terms.
Sources: CMS-0057-F Final Rule (Jan 2024), KFF Prior Authorization Analysis (2023), OIG Medicare Advantage Denial Reports. Ellen is an educational tool and does not provide medical or legal advice.