Who Appeals the Other 128,597 Denials?
Centene's five California plans published their CY2025 prior authorization metrics because CMS-0057-F made them. Their own filings say 47% of appealed denials got reversed, and 1.6% of denials were ever appealed.
Five prior authorization metrics summaries sit on Health Net's provider site, posted because CMS-0057-F told the company to post them. Between them they cover 4,454,823 requests decided in 2025, 130,734 denials, and 2,137 appeals.
Two thousand one hundred thirty-seven, against a hundred and thirty thousand denials.
Of those appeals, 1,005 ended with the plan approving what it had already refused. That is a 47.03% reversal rate on the cases somebody pushed, and a 1.635% push rate on the cases available.
"If the house loses half the hands, why does almost nobody sit down?"
The spread by book is the part worth your afternoon.
Wellcare By Health Net's two Medicare Advantage contracts, H0562 and H3561, reversed 80.9% and 78.3% of the appeals they received, on appeal rates of 2.7% and 2.2% of denials (chart below). The three Medi-Cal filings reverse between 39% and 48%, and get appealed even less.
The Same Company, Filing Five Different Answers
All five documents come out of one corporate structure.
The footers say so: Health Net of California, Health Net Community Solutions and Health Net Life Insurance are subsidiaries of Health Net, LLC and Centene Corporation. Same parent, same template, same measurement year, same stamp of "Effective December 31, 2025."
And the denial rates run from 1.94% on the H0562 standard book to 7.57% at Community Health Plan of Imperial Valley.
So a patient's card decides your exposure four times over before anyone looks at the clinical question.
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