Medicare Part D: The Medicare prescription drug benefit program. We call this program “Part D” for short. Medicare Part D covers outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Medicare Part B or Medical Assistance. Our plan includes Medicare Part D.Medicare Part A: The Medicare program that covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part B: The Medicare program that covers services (such as lab tests, surgeries, and doctor visits) and supplies (such as wheelchairs and walkers) that are medically necessary to treat a disease or condition. Medicare Part B also covers many preventive and screening services.Medical Assistance: This is the name of Minnesota’s Medicaid program. Medical Assistance is run by the state and is paid for by the state and the federal government. It helps people with limited incomes and resources pay for long-term services and supports and medical costs.
It covers extra services and some drugs not covered by Medicare. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Prior Authorization and Appeals Data

Data for these tables is not yet available. Any information shown is for testing purposes only. Please check back at a later date for updates.

CMS Prior Authorization Metrics for Medical Items & Services

To comply with the CMS Interoperability and Prior Authorization final rule, South Country Health Alliance will annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year.

Reporting Period: 2025 **These are the medical items and services for which we required prior authorization (excluding drugs) for the indicated year.

Medical Items & Services for which prior authorization is required

Prior authorization grids and code lookups are located here: Authorizations

Prior Authorization and Appeals Data-Medicare

YearContractRequest TypeApproved (%)Denied (%)Appeal RequestsApproved after Appeal (%)Extended- Approved
2025H2419/SeniorCare CompleteStandard99.7%.30%N/A
2025H2419/SeniorCare CompleteUrgent100%N/AN/A
2025H5703/AbilityCareStandardN/A
2025H5703/AbilityCareUrgentN/AN/A
2025MedicaidStandardN/A
2025MedicaidUrgentN/AN/A
*There were no extended authorizations in 2025

Turnaround Time

YearContractTimeframeMean (Average) TimeMedian (Middle Time)
2025H2419Standard
2025H2419Urgent
2025H5703Standard
2025H5703Urgent

MN-DHS Prior Authorization Reporting

To comply with the Minnesota Department of Human Services contract requirements and the Minnesota 62M statute, South Country Health Alliance will annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year.

Prior Authorization and Appeal Data

*This data includes all South Country’s products/lines of business: SeniorCare Complete, MSC+, AbilityCare, SingleCare, SharedCare, Families and Children (PMAP) and MinnesotaCare.

Prior Authorization and Appeal Data-Medical Assistance

YearService CategoryTotal ReviewsApprovalsDenialsTotal AppealsAppeal UpheldAppeal ReversedElectronically Submitted

Denial Reasons with Count

  • Patient did not meet prior authorization criteria (count)
  • Services are not considered to be medically necessary (count)
  • Incomplete information submitted by the provider to the utilization review organization (count)
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