UM approval and denial rates are calculated at the request level, not at the service or code level. A request is counted once in the denominator, regardless of how many services it includes. If any part of the request is approved, it counts as 1 approval. If any part is denied, it counts as 1 denial. Therefore, a partially approved and partially denied request is included in both the approval and denial rates.
For example, if one authorization request includes three CPT codes and one is approved while two are denied, the organization counts:
- 1 approval decision (count in the approval rate numerator),
- 1 denial decision (count in the denial rate numerator),
- 1 authorization request (count once in the approval and denial denominator).
As another example, if an organization made decisions on 300,000 total authorization requests, and:
- 200,000 were completely approved,
- 50,000 were partially approved/denied, and
- 50,000 were completely denied,
the rates would be calculated as follows:
- Overall approval rate: ((200,000 + 50,000) / 300,000) x 100 = 83%.
- Overall denial rate: ((50,000 + 50,000) / 300,000) x 100 = 33%.
The overall approval rate cannot exceed 100%, and the overall denial rate cannot exceed 100%. However, if an organization sums these two rates, the combined total may exceed 100%.
Applicable standards:
- Health Plan Accreditation – UM 1, Elements B-E
- Behavioral Health Accreditation – UM 1, Elements B-D
- Utilization Management Accreditation – UM 3, Elements B-E
