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

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. [CFR 438.210(f)]

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

For 2025, our prior authorization grid is located here: Authorizations-South Country Health Alliance

To see what medical services and items currently require prior authorization, please use our PA Lookup Tool located here: Authorizations – South Country Health Alliance

Timelines

Prior to January 1, 2026, South Country Health Alliance was contractually required to provide prior authorization determinations in the time frames below:

  • 14 calendar days for standard requests (non-urgent); and
  • 72 hours for expedited requests (urgent)

*Extensions for standard requests allow for up to 14 additional days to provide the determination.

Beginning January 1, 2026, the CMS Interoperability and Prior Authorization final rule and Minnesota DHS contracts require South Country Health Alliance to send prior authorization decisions within:

  • Five (5) business days for standard requests (non-urgent); and
  • 72 hours for expedited requests (urgent)

*Extensions for standard requests allow for up to 14 additional days to provide the determination.

Prior Authorization and Appeals Data-Medicare

ContractRequest TypeApproved (%)Denied (%)Extended- ApprovedApproved after Appeal (%)
H2419/SeniorCare CompleteStandard99%1%N/AN/A
H2419/SeniorCare CompleteUrgent100%N/AN/AN/A
H5703/AbilityCareStandard100%N/AN/AN/A
H5703/AbilityCareUrgent100%N/AN/AN/A
MedicaidStandard99.7%0.3%N/A50%
MedicaidUrgent100%N/AN/AN/A
*Denied includes Partially Approved
*No extensions in 2025
*Does not include medical pharmacy (Outpatient and Part B), retail pharmacy or dental

2025 Turnaround Time

ContractTimeframeMean (Average) TimeMedian (Middle Time)
H2419Standard2 days2 days
H2419Urgent1.5 days1.5 days
H5703Standard2 days2 days
H5703Urgent1.5 days1.5 days
MedicaidStandard2.3 days2 days
MedicaidUrgent1.4 days1 days

MN-DHS Prior Authorization Reporting

To comply with the Minnesota Department of Human Services contract requirements and the Minnesota 62M statute (62M.18), 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.

Definitions:

  • An approval means that all the services/items requested in the prior authorization were fully approved
  • A denial means that all the services/items requested in the prior authorization were fully denied for reasons listed under “denial reasons.”
    • A denial, for this reporting, also includes “partial approvals/denials.” A “partial” approval or denial means that not all the services/items requested in the prior authorization were fully approved.
  • An appeal means that the member, the member’s provider or authorized representative, requested a secondary review of a denial because they did not agree with our determination. When a member appeals a prior authorization request, upon review, that initial determination (decision) can be upheld (it stays denied), or reversed (it is partially or fully approved).
  • An authorization request that is submitted electronically means it was submitted via South Country’s Provider Portal or via an integration with a providers’ electronic medical record. Electronically submitted authorizations do not include requests submitted via fax, email or phone call.

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

Service CategoryApprovalsDenialsUpheld on AppealReversed on AppealSubmitted Electronically
Outpatient Medical1,209511339
Medicare Part B Drugs1400N/AN/A0
Medicaid Outpatient Drugs26977282
Outpatient Behavioral Health1310N/AN/A2
Dental1,6358901592,496
Retail Pharmacy3,0931,12717725,125*
*Retail Pharmacy Submitted Electronically includes all PA requests which would include closed/withdrawn requests that are not accounted for in this table.
*Medicare Part B Drugs and Medicaid Outpatient Drugs are physician administered drugs.

Denial Reasons

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

Last Updated on 03/27/2026 by Chris Gartner

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