Insurance Company Profiles

Understand how major insurers approach prior authorization and coverage decisions.

Why Know Your Insurer?

Different insurers have different prior authorization thresholds, documentation standards, and appeal processes. Understanding your insurer's approach helps you prepare a stronger case before you submit — and mount a more effective appeal if denied.

UnitedHealthcare

Largest private health insurer in the US, serving over 50 million members through employer, individual, and government programs.

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Reputation

Known for rigorous prior authorization requirements and strict medical necessity standards.

Key Prior Auth Policies

  • •Requires PA for most imaging (MRI, CT) except emergency situations
  • •Step therapy protocols for specialty medications
  • •Medical review officers review denials within 30-45 days
  • •Strict frequency limits on physical therapy (typically 30 visits/year)

Appeal Process

Two-tier appeal system: Internal appeal (60 days) followed by external independent review. Network physicians may conduct peer-to-peer reviews.

Anthem BCBS

Large regional BCBS plan operating in multiple states. Part of Elevance Health, serving millions of covered lives.

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Reputation

Mixed reputation; some states have stricter authorization processes than others.

Key Prior Auth Policies

  • •Prior auth required for advanced imaging (MRI, CT, PET)
  • •Bariatric surgery requires 6-month supervised diet program documentation
  • •Mental health visit limits vary by plan type
  • •State-specific policies may differ from national guidelines

Appeal Process

State-specific appeal processes. Internal appeal timeframes typically 30 days for expedited, 60 days for standard. External review available in all states.

Aetna (CVS Health)

Major integrated health insurance and pharmacy provider, now fully owned by CVS Health. Covers millions nationwide.

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Reputation

Known for bundled care models and tying insurance decisions to pharmacy coverage.

Key Prior Auth Policies

  • •Integrated pharmacy and medical prior auth for certain procedures
  • •PreferredOne network model emphasizes care coordination
  • •Requires documentation of conservative treatment attempts (physical therapy, injections) before surgery approval
  • •Aggressive step therapy protocols for mental health medications

Appeal Process

Internal appeal (30 days standard, 72 hours expedited). External review follows state timelines. CVS pharmacy integration may affect appeal outcomes for integrated treatments.

Cigna

Global health services company providing medical, dental, and behavioral health insurance across the US and internationally.

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Reputation

Moderate reputation; known for reasonable initial approval rates but complex appeal processes.

Key Prior Auth Policies

  • •Prior auth required for imaging over $500 estimated cost
  • •Behavioral health referral required for mental health treatment (often delayed)
  • •Telehealth preferred over in-person for certain conditions
  • •Quantity limits on diagnostic testing (e.g., annual imaging limits)

Appeal Process

Standard internal appeal: 30-60 days. Expedited appeal available for urgent cases. External Independent Review Organization (IRO) process takes 30-45 days.

Humana

Major health insurer focused on Medicare Advantage and Medicaid plans, with growing commercial presence.

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Reputation

Frequently cited in denial disputes; strict on elderly/complex patient approvals.

Key Prior Auth Policies

  • •High volume of Medicare Advantage denials reported
  • •Prior auth for most specialist visits in MA plans
  • •Restrictive coverage for new/emerging treatments
  • •Pharmacy Step Therapy very common, especially for biologic medications

Appeal Process

Medicare Advantage plans have expedited appeal rights (72 hours). Standard internal appeal 30-60 days. External review available; may be faster for MA plans.

Kaiser Permanente

Integrated health system and insurer with regional presence in CA, CO, OR, WA, HI. Owns hospitals, clinics, and pharmacies.

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Reputation

Generally rated favorably; unified medical and insurance model streamlines approvals.

Key Prior Auth Policies

  • •Internal unified system (insurer + provider) may expedite decisions
  • •Referral required for specialist care, but often waived for urgent needs
  • •Strong emphasis on preventive care coverage
  • •Prior auth more common for out-of-network referrals

Appeal Process

Internal appeals fast-tracked (often 5-10 days) due to integrated model. External appeal available through state regulatory processes. In-network provider advocacy may help.

Blue Cross Blue Shield (General)

Largest insurance network in the US, administered by 35+ independent licensed Blue companies with regional autonomy.

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Reputation

Highly variable by state and specific Blue plan; regional differences significant.

Key Prior Auth Policies

  • •Prior auth policies vary significantly by state and plan
  • •Many regional Blues have strong provider networks and faster approvals
  • •Digital tools and online portals often robust and user-friendly
  • •State-specific mandates may improve coverage for certain procedures

Appeal Process

Appeal process varies by Blue plan and state. Most follow 30-60 day internal timeline. Request specific Blue company guidelines for your state.

Molina Healthcare

Managed care company primarily serving Medicaid and Medicare Advantage populations across multiple states.

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Reputation

Mixed; high Medicaid volume but variable quality of reviews and appeals.

Key Prior Auth Policies

  • •Prior auth required for many Medicaid services (varies by state)
  • •More restrictive on specialty referrals in Medicaid plans
  • •Medicare Advantage plans subject to CMS prior auth standards
  • •State regulatory environment heavily influences coverage decisions

Appeal Process

Medicaid appeal timelines vary by state (typically 30 days internal). Medicare Advantage: 72-hour expedited and 30-day standard appeals available. State Medicaid agencies often have ombudsman programs to help.

Medicare (CMS)

Federal program administered by Centers for Medicare and Medicaid Services (CMS). Covers Americans 65+ and some younger disabled/ESRD patients.

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Reputation

Generally less restrictive than commercial plans; clear national guidelines.

Key Prior Auth Policies

  • •National Coverage Determination (NCD) and Local Coverage Determination (LCD) rules apply
  • •Prior auth not required for most services, but medical review may occur post-service
  • •Specific CPT code bundles and frequency limits enforced
  • •Regional Fiscal Intermediaries handle claims and appeals

Appeal Process

Multi-level appeal process: Redetermination (120 days), Reconsideration (180 days), Administrative Law Judge hearing, Appeals Council, and federal court. Request Explanation of Benefits (EOB) to start process.

Medicaid (State Programs)

Joint federal-state insurance program for low-income individuals. Administered by each state with varying coverage, eligibility, and rules.

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Reputation

Highly variable by state; some states have robust coverage, others very restrictive.

Key Prior Auth Policies

  • •Prior auth requirements, frequency limits, and covered services vary by state
  • •Income and asset limits determine eligibility (state-specific)
  • •Managed care organizations often administer state Medicaid benefits
  • •Federal expansion states may have broader coverage than non-expansion states

Appeal Process

Appeal process and timelines vary by state. Many states have Medicaid ombudsman programs. State Medicaid agency and managed care plan have different appeal paths — both may be available. Contact your state Medicaid program directly.

Key Takeaways for Patients

1

Know your specific plan type

Medicare Advantage, Medicaid, and commercial plans within the same insurer may have different rules. Check your plan documents.

2

Get pre-authorization in writing

Don't rely on verbal approval from a nurse. Ask for written prior authorization before the procedure.

3

Understand your state's regulations

State Departments of Insurance (DOI) set minimum appeal standards. Your state may grant you stronger protections than federal law.

4

Use your provider as an ally

Your healthcare provider often has better luck with peer-to-peer reviews and appeals than you will alone. Ask them to advocate for you.

5

Document everything

Keep copies of all prior auth requests, denials, appeal letters, and supporting medical documentation. You'll need them.

Ready to Build Your Case?

Use our Appeal Prompt Generator to create a customized appeal letter backed by documentation checklists and insurer-specific strategies.

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This information is for educational purposes only and is not medical, legal, or financial advice. Coverage decisions depend on your specific plan, insurer, and clinical circumstances. Always verify with your insurance company and healthcare provider.