{ "meta": { "total": 536, "page": 1, "per_page": 50, "pages": 11, "sort": "rate", "direction": "desc", "reporting_year": "CY2025", "rule": "CMS-0057-F", "note": "Rates are computed from published counts. null means the payer published no value; it never means zero." }, "filings": [ { "filing_id": "f0527", "parent_org": "VillageCare", "plan_name": "VillageCareMAX Managed Long-Term Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 62.3, "std_denial_rate_printed": 62.3, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 4.3, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 46.6, "ext_review_approved": null, "std_tat_mean_days": 7.28, "std_tat_median_days": 5, "exp_tat_mean_hours": 92.64, "exp_tat_median_hours": 24, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.villagecaremax.org/prior-authorizations-reporting", "source_segment": "ca_ny", "extraction_note": "HIGHEST DENIAL RATE IN THE DATASET: 62.3% standard, 46.6% expedited. Only 4.3% of appeals overturned. Expedited mean of 3.86 days (92.6h) far exceeds any expedited standard. Percentages only, no counts to check against." }, { "filing_id": "f0250", "parent_org": "Hamaspik", "plan_name": "Hamaspik Medicare Choice (MAP - Medicaid side)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 52, "std_denial_rate_printed": 52, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 8, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 7.84, "std_tat_median_days": 3.59, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.hamaspik.com/priorauthdata?hsLang=en", "source_segment": "w3_ky_nc_ms_ny", "extraction_note": "MAP = Medicaid Advantage Plus; this column is the Medicaid-side reporting for Hamaspik's dual-eligible integrated plan (the Medicare-side is reported separately as 'Hamaspik Medicare Select'). Expedited approved and denied are BOTH printed as 0%, and no expedited turnaround time is shown at all - this most likely reflects zero expedited-request volume for this plan rather than a measured 0% denial rate; recorded as printed, flagged rather than omitted or treated as null. Percentages only, no counts. 'Extended timeframe approved' (9%) not stored - field expects a count." }, { "filing_id": "f0249", "parent_org": "Hamaspik", "plan_name": "Hamaspik Choice (MLTC)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 49, "std_denial_rate_printed": 49, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 15, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 16, "ext_review_approved": null, "std_tat_mean_days": 7.59, "std_tat_median_days": 4.28, "exp_tat_mean_hours": 101.28, "exp_tat_median_hours": 61.44, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.hamaspik.com/priorauthdata?hsLang=en", "source_segment": "w3_ky_nc_ms_ny", "extraction_note": "Source page's turnaround table header labels both standard and expedited columns '(days)'; expedited mean/median (4.22d / 2.56d as printed) were converted to hours (101.28 / 61.44). Percentages only ('aggregated for all items & services'), no total request counts published. Page's 'Extended timeframe approved' figure (15%) not stored - field expects a count, not a percentage." }, { "filing_id": "f0019", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "AmeriHealth Caritas Delaware CHIP", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "DE", "reporting_period": "CY2025", "std_total": 2764, "std_approved": 1426, "std_denied": 1338, "std_denial_rate": 48.41, "std_denial_rate_printed": 48.4, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 35, "exp_approved": 24, "exp_denied": 11, "exp_denial_rate": 31.43, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 2, "exp_tat_mean_hours": 36.3, "exp_tat_median_hours": 31, "reports_counts": true, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://www.amerihealthcaritasde.com/rights/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "CHIP table published on the same page as the Delaware Medicaid table. No appeal outcome counts printed for the CHIP product." }, { "filing_id": "f0403", "parent_org": "UCare", "plan_name": "Prepaid Medical Assistance Program (PMAP)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MN", "reporting_period": "CY2025", "std_total": 30736, "std_approved": 16043, "std_denied": 14693, "std_denial_rate": 47.8, "std_denial_rate_printed": null, "std_appeals_total": 850, "std_appeals_overturned": 113, "std_appeal_overturn_rate": 13.29, "exp_total": 469, "exp_approved": 356, "exp_denied": 113, "exp_denial_rate": 24.09, "ext_review_approved": 0, "std_tat_mean_days": 6, "std_tat_median_days": 8, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport__PMAP_2026.pdf", "source_segment": "sweep", "extraction_note": "Mean standard TAT (6 days) is below the median (8 days)." }, { "filing_id": "f0405", "parent_org": "UCare", "plan_name": "UCare Connect + Medicare", "contract_id": "H5937", "coverage_type": "Medicare Advantage", "state": "MN", "reporting_period": "CY2025", "std_total": 3685, "std_approved": 1969, "std_denied": 1716, "std_denial_rate": 46.57, "std_denial_rate_printed": null, "std_appeals_total": 107, "std_appeals_overturned": 32, "std_appeal_overturn_rate": 29.91, "exp_total": 241, "exp_approved": 201, "exp_denied": 40, "exp_denial_rate": 16.6, "ext_review_approved": 0, "std_tat_mean_days": 6, "std_tat_median_days": 7, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport__ConnectPlus_H5937_2026.pdf", "source_segment": "sweep", "extraction_note": "Integrated Medicare-Medicaid special needs product under an MA contract." }, { "filing_id": "f0404", "parent_org": "UCare", "plan_name": "UCare Connect", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MN", "reporting_period": "CY2025", "std_total": 6578, "std_approved": 3606, "std_denied": 2972, "std_denial_rate": 45.18, "std_denial_rate_printed": null, "std_appeals_total": 142, "std_appeals_overturned": 47, "std_appeal_overturn_rate": 33.1, "exp_total": 200, "exp_approved": 135, "exp_denied": 65, "exp_denial_rate": 32.5, "ext_review_approved": 0, "std_tat_mean_days": 7, "std_tat_median_days": 8, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport__Connect_2026.pdf", "source_segment": "sweep", "extraction_note": "Special Needs BasicCare (Medicaid-only) product." }, { "filing_id": "f0402", "parent_org": "UCare", "plan_name": "MinnesotaCare (MnCare)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MN", "reporting_period": "CY2025", "std_total": 6208, "std_approved": 3406, "std_denied": 2802, "std_denial_rate": 45.14, "std_denial_rate_printed": null, "std_appeals_total": 66, "std_appeals_overturned": 8, "std_appeal_overturn_rate": 12.12, "exp_total": 70, "exp_approved": 54, "exp_denied": 16, "exp_denial_rate": 22.86, "ext_review_approved": 0, "std_tat_mean_days": 8, "std_tat_median_days": 8, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport__MnCare_2026.pdf", "source_segment": "sweep", "extraction_note": "MinnesotaCare is a Basic Health Program; no exact enum exists, recorded as Medicaid Managed Care." }, { "filing_id": "f0407", "parent_org": "UCare", "plan_name": "UCare Minnesota Senior Health Options (MSHO)", "contract_id": "H2456", "coverage_type": "Medicare Advantage", "state": "MN", "reporting_period": "CY2025", "std_total": 4469, "std_approved": 2506, "std_denied": 1963, "std_denial_rate": 43.92, "std_denial_rate_printed": null, "std_appeals_total": 102, "std_appeals_overturned": 26, "std_appeal_overturn_rate": 25.49, "exp_total": 612, "exp_approved": 563, "exp_denied": 49, "exp_denial_rate": 8.01, "ext_review_approved": 0, "std_tat_mean_days": 6, "std_tat_median_days": 7, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport__MSHO_H2456_2026.pdf", "source_segment": "sweep", "extraction_note": "Integrated Medicare-Medicaid product operating under an MA contract." }, { "filing_id": "f0401", "parent_org": "UCare", "plan_name": "Minnesota Senior Care Plus (MSC+)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MN", "reporting_period": "CY2025", "std_total": 1101, "std_approved": 640, "std_denied": 461, "std_denial_rate": 41.87, "std_denial_rate_printed": null, "std_appeals_total": 15, "std_appeals_overturned": 4, "std_appeal_overturn_rate": 26.67, "exp_total": 28, "exp_approved": 17, "exp_denied": 11, "exp_denial_rate": 39.29, "ext_review_approved": 0, "std_tat_mean_days": 8, "std_tat_median_days": 8, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport__MSCPlus_2026.pdf", "source_segment": "sweep", "extraction_note": "Expedited TAT published in days, x24." }, { "filing_id": "f0444", "parent_org": "UnitedHealth Group", "plan_name": "Texas MMP", "contract_id": null, "coverage_type": "Medicare-Medicaid Plan", "state": "TX", "reporting_period": "CY2025", "std_total": 240, "std_approved": 143, "std_denied": 97, "std_denial_rate": 40.42, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 0, "std_appeal_overturn_rate": null, "exp_total": 8, "exp_approved": 8, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 0, "std_tat_median_days": 0.5, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 7.2, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicaid-2025.pdf", "source_segment": "wave2", "extraction_note": "40.4% standard denial rate on a small base." }, { "filing_id": "f0521", "parent_org": "Univera Healthcare", "plan_name": "Univera Healthcare Medicare D-SNP (HMO)", "contract_id": "H7524", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 118, "std_approved": 75, "std_denied": 43, "std_denial_rate": 36.44, "std_denial_rate_printed": 36.4, "std_appeals_total": 3, "std_appeals_overturned": 1, "std_appeal_overturn_rate": 33.33, "exp_total": 3, "exp_approved": 3, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 2.5, "std_tat_median_days": 2, "exp_tat_mean_hours": 36, "exp_tat_median_hours": 45.6, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/univerametrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Dual-eligible SNP; coded Medicare Advantage. 63.6% standard approval on a very small base (118 requests). Same shared-contract-ID caveat." }, { "filing_id": "f0400", "parent_org": "UCare", "plan_name": "EssentiaCare Plans", "contract_id": "H8783", "coverage_type": "Medicare Advantage", "state": "MN", "reporting_period": "CY2025", "std_total": 382, "std_approved": 248, "std_denied": 134, "std_denial_rate": 35.08, "std_denial_rate_printed": null, "std_appeals_total": 8, "std_appeals_overturned": 6, "std_appeal_overturn_rate": 75, "exp_total": 38, "exp_approved": 36, "exp_denied": 2, "exp_denial_rate": 5.26, "ext_review_approved": 0, "std_tat_mean_days": 1, "std_tat_median_days": 0, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport_EssentiaCare_H8783_2026.pdf", "source_segment": "sweep", "extraction_note": "State not printed; MN assigned from the publisher." }, { "filing_id": "f0031", "parent_org": "Blue Cross Blue Shield of Michigan", "plan_name": "Blue Cross Complete of Michigan", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MI", "reporting_period": "CY2025", "std_total": 243159, "std_approved": 158307, "std_denied": 84816, "std_denial_rate": 34.88, "std_denial_rate_printed": 34.9, "std_appeals_total": null, "std_appeals_overturned": 893, "std_appeal_overturn_rate": null, "exp_total": 11241, "exp_approved": 9318, "exp_denied": 1921, "exp_denial_rate": 17.09, "ext_review_approved": null, "std_tat_mean_days": 5.9, "std_tat_median_days": 4, "exp_tat_mean_hours": 31.8, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.mibluecrosscomplete.com/important-information/prior-authorization/", "source_segment": "blues", "extraction_note": "OUTLIER: 34.90% standard denial rate is several times higher than any other filing in this segment - worth verifying against the plan's own PDF before use. Approved+denied (158,307+84,816=243,123) is 36 short of the stated 243,159 total, which matches the separately reported 36 'approved other than requested' (2 for expedited). Appeals: only overturn COUNTS are published (893 standard, 60 expedited) with no appeal denominator, so std_appeals_total and overturn pct are null. Extended review published only as a percentage of approved requests (1.10% standard, 0.20% expedited), so ext_review counts are null. This is the BCBSM Medicaid subsidiary; no separate BCBSM commercial/MA filing was located." }, { "filing_id": "f0426", "parent_org": "UnitedHealth Group", "plan_name": "Massachusetts Senior Care Options", "contract_id": null, "coverage_type": "Medicare-Medicaid Plan", "state": "MA", "reporting_period": "CY2025", "std_total": 84, "std_approved": 56, "std_denied": 28, "std_denial_rate": 33.33, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 0, "std_appeal_overturn_rate": null, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": null, "ext_review_approved": null, "std_tat_mean_days": 0, "std_tat_median_days": 0.7, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicaid-2025.pdf", "source_segment": "wave2", "extraction_note": "No expedited row present in source." }, { "filing_id": "f0135", "parent_org": "Centene", "plan_name": "Ambetter from Superior HealthPlan (29418)", "contract_id": "29418", "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": 218062, "std_approved": 146238, "std_denied": 71824, "std_denial_rate": 32.94, "std_denial_rate_printed": null, "std_appeals_total": 3439, "std_appeals_overturned": 2129, "std_appeal_overturn_rate": 61.91, "exp_total": 6747, "exp_approved": 5145, "exp_denied": 1602, "exp_denial_rate": 23.74, "ext_review_approved": 29074, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 72, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://www.ambetterhealth.com/content/dam/centene/Superior/Ambetter/PDFs/TX_MKT_ABSuperiorHealthPlan_29418_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "contract_id is the HIOS issuer ID. 32.9% standard denial rate on 218,062 requests - the highest-volume high-denial filing in the dataset." }, { "filing_id": "f0136", "parent_org": "Centene", "plan_name": "Ambetter from Superior HealthPlan (87226)", "contract_id": "87226", "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": 89666, "std_approved": 60540, "std_denied": 29126, "std_denial_rate": 32.48, "std_denial_rate_printed": null, "std_appeals_total": 1297, "std_appeals_overturned": 779, "std_appeal_overturn_rate": 60.06, "exp_total": 4992, "exp_approved": 3453, "exp_denied": 1539, "exp_denial_rate": 30.83, "ext_review_approved": 13243, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 72, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://www.ambetterhealth.com/content/dam/centene/Superior/Ambetter/PDFs/TX_MKT_ABSuperiorHealthPlan_87226_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "contract_id is the HIOS issuer ID. 32.5% standard denial rate." }, { "filing_id": "f0167", "parent_org": "Centene", "plan_name": "Oklahoma Complete Health - SoonerSelect", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "OK", "reporting_period": "CY2025", "std_total": 72761, "std_approved": 49167, "std_denied": 23594, "std_denial_rate": 32.43, "std_denial_rate_printed": null, "std_appeals_total": 1328, "std_appeals_overturned": 840, "std_appeal_overturn_rate": 63.25, "exp_total": 1348, "exp_approved": 1047, "exp_denied": 301, "exp_denial_rate": 22.33, "ext_review_approved": 2025, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.oklahomacompletehealth.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/OK_OKCH_Medicaid_SSP_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "32.4% standard denial rate on 72,761 requests." }, { "filing_id": "f0139", "parent_org": "Centene", "plan_name": "Ambetter of Oklahoma", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "OK", "reporting_period": "CY2025", "std_total": 38282, "std_approved": 26755, "std_denied": 11527, "std_denial_rate": 30.11, "std_denial_rate_printed": 30.11, "std_appeals_total": 777, "std_appeals_overturned": 232, "std_appeal_overturn_rate": 29.86, "exp_total": 733, "exp_approved": 570, "exp_denied": 163, "exp_denial_rate": 22.24, "ext_review_approved": null, "std_tat_mean_days": 3, "std_tat_median_days": 1, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.ambetterhealth.com/content/dam/centene/ambetter-of-oklahoma/pdf/OK_MKT_ABofOK_62505_MetricsSummary_R.pdf", "source_segment": "w3_qhp", "extraction_note": "Issuer ID 62505. Expedited appeals: 52 total, 25 overturned (48.08%). Expedited TAT printed in days (mean 2, median 1); converted to hours (48h/24h) - native unit was days." }, { "filing_id": "f0111", "parent_org": "California DHCS", "plan_name": "Medi-Cal Dental Fee-for-Service", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "CA", "reporting_period": "CY2025", "std_total": 3138788, "std_approved": 2212669, "std_denied": 926119, "std_denial_rate": 29.51, "std_denial_rate_printed": null, "std_appeals_total": 2430, "std_appeals_overturned": 1623, "std_appeal_overturn_rate": 66.79, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": null, "ext_review_approved": 188, "std_tat_mean_days": 4.8, "std_tat_median_days": 5, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.dhcs.ca.gov/vi/provgovpart/Documents/Interoperability-Prior-Auth-Metrics-Reports/Medi-Cal-Dental-2025-Prior-Auth-Metrics.pdf", "source_segment": "states", "extraction_note": "Expedited not separately available. Median (5 days) exceeds mean (4.8). Of 24,230 extensions, only 188 approved and 24,042 denied." }, { "filing_id": "f0237", "parent_org": "Excellus BlueCross BlueShield", "plan_name": "Excellus BCBS Medicare D-SNP (HMO)", "contract_id": "H7524", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 2327, "std_approved": 1645, "std_denied": 682, "std_denial_rate": 29.31, "std_denial_rate_printed": 29.3, "std_appeals_total": 27, "std_appeals_overturned": 6, "std_appeal_overturn_rate": 22.22, "exp_total": 29, "exp_approved": 24, "exp_denied": 5, "exp_denial_rate": 17.24, "ext_review_approved": null, "std_tat_mean_days": 1.8, "std_tat_median_days": 1, "exp_tat_mean_hours": 16.8, "exp_tat_median_hours": 19.2, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/excellusmetrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Contract H7524. Dual-eligible SNP; coded Medicare Advantage. 70.7% standard approval is far below the plan's other Medicare lines. Only 27 appeals against 682 denials." }, { "filing_id": "f0406", "parent_org": "UCare", "plan_name": "UCare Medicare Plans", "contract_id": "H2459", "coverage_type": "Medicare Advantage", "state": "MN", "reporting_period": "CY2025", "std_total": 18305, "std_approved": 13013, "std_denied": 5292, "std_denial_rate": 28.91, "std_denial_rate_printed": null, "std_appeals_total": 208, "std_appeals_overturned": 109, "std_appeal_overturn_rate": 52.4, "exp_total": 2011, "exp_approved": 1911, "exp_denied": 100, "exp_denial_rate": 4.97, "ext_review_approved": 0, "std_tat_mean_days": 2, "std_tat_median_days": 0, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/74U15479_PAMetricsReport__Medicare_H2459_2026.pdf", "source_segment": "sweep", "extraction_note": "State not printed; MN assigned from publisher." }, { "filing_id": "f0529", "parent_org": "VillageCare", "plan_name": "VillageCareMAX Total Advantage (D-SNP) - Medicaid requests", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 28.6, "std_denial_rate_printed": 28.6, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 13.5, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 15.7, "ext_review_approved": null, "std_tat_mean_days": 4.84, "std_tat_median_days": 3, "exp_tat_mean_hours": 20.88, "exp_tat_median_hours": 0, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.villagecaremax.org/prior-authorizations-reporting", "source_segment": "ca_ny", "extraction_note": "Percentages only. Expedited TAT converted days->hours." }, { "filing_id": "f0137", "parent_org": "Centene", "plan_name": "Ambetter of Alabama", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "AL", "reporting_period": "CY2025", "std_total": 38711, "std_approved": 27669, "std_denied": 11042, "std_denial_rate": 28.52, "std_denial_rate_printed": 28.52, "std_appeals_total": 903, "std_appeals_overturned": 264, "std_appeal_overturn_rate": 29.24, "exp_total": 1252, "exp_approved": 964, "exp_denied": 288, "exp_denial_rate": 23, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.ambetterhealth.com/content/dam/centene/ambetterofalabama/pdfs/AL_MKT_ABofAL_53932_MetricsSummary_R.pdf", "source_segment": "w3_qhp", "extraction_note": "Issuer ID 53932. Expedited appeals: 60 total, 29 overturned (48.33%). Expedited TAT printed in days (mean 1, median 1); converted to hours (24h/24h) - native unit was days." }, { "filing_id": "f0016", "parent_org": "AmeriHealth Caritas", "plan_name": "Keystone First", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "PA", "reporting_period": "CY2025", "std_total": 314611, "std_approved": 234056, "std_denied": 89408, "std_denial_rate": 28.42, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 792, "std_appeal_overturn_rate": null, "exp_total": 1933, "exp_approved": 1523, "exp_denied": 410, "exp_denial_rate": 21.21, "ext_review_approved": null, "std_tat_mean_days": 4.8, "std_tat_median_days": 2, "exp_tat_mean_hours": 66.87, "exp_tat_median_hours": 17, "reports_counts": true, "quality_flags": "error:std_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://www.keystonefirstpa.com/member/rights/prior-authorization-reporting", "source_segment": "states", "extraction_note": "INTERNAL INCONSISTENCY: percentages sum to 102.8%, and 234,056 + 89,408 = 323,464 EXCEEDS the stated total of 314,611." }, { "filing_id": "f0128", "parent_org": "Centene", "plan_name": "Ambetter from Buckeye Health Plan", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "OH", "reporting_period": "CY2025", "std_total": 52991, "std_approved": 37954, "std_denied": 15037, "std_denial_rate": 28.38, "std_denial_rate_printed": 28.38, "std_appeals_total": 441, "std_appeals_overturned": 251, "std_appeal_overturn_rate": 56.92, "exp_total": 3499, "exp_approved": 2657, "exp_denied": 842, "exp_denial_rate": 24.06, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 2, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.ambetterhealth.com/content/dam/centene/Buckeye/Ambetter/PDFs/OH_MKT_ABBuckeyeHealthPlan_41047_MetricsSummary_R.pdf", "source_segment": "w3_qhp", "extraction_note": "Issuer ID 41047. Document also includes an expedited appeals line (61 total, 30 overturned, 49.18%) not captured in fixed fields; std/exp appeals overturned pct printed as 56.92%/49.18% respectively. Expedited TAT printed in days (mean 1 day, median 0 days); converted to hours per schema (24h mean, 0h median) - document's native unit is days, not hours, so treat with care." }, { "filing_id": "f0112", "parent_org": "California DHCS", "plan_name": "Medi-Cal Fee-for-Service (medical and behavioral health)", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "CA", "reporting_period": "CY2025", "std_total": 78987, "std_approved": 55741, "std_denied": 22404, "std_denial_rate": 28.36, "std_denial_rate_printed": null, "std_appeals_total": 43, "std_appeals_overturned": 3, "std_appeal_overturn_rate": 6.98, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": null, "ext_review_approved": 774, "std_tat_mean_days": 4, "std_tat_median_days": 2, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": true, "quality_flags": "warn:std_headline_excludes_extended", "error_count": 0, "warn_count": 1, "source_url": "https://www.dhcs.ca.gov/vi/provgovpart/Documents/Interoperability-Prior-Auth-Metrics-Reports/Medi-Cal-2025-Prior-Auth-Metrics.pdf", "source_segment": "states", "extraction_note": "Expedited data explicitly not available; standard and expedited reported together. Third outcome category 'Modified' = 842. CONTRADICTION: prints 3 of 43 appeals approved but labels it 14%; 3/43 is 7%. Also reports 9,439 auto-denied after extension." }, { "filing_id": "f0018", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "AmeriHealth Caritas Delaware (Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "DE", "reporting_period": "CY2025", "std_total": 70575, "std_approved": 50588, "std_denied": 19987, "std_denial_rate": 28.32, "std_denial_rate_printed": 28.3, "std_appeals_total": null, "std_appeals_overturned": 305, "std_appeal_overturn_rate": null, "exp_total": 6971, "exp_approved": 6110, "exp_denied": 861, "exp_denial_rate": 12.35, "ext_review_approved": null, "std_tat_mean_days": 3.4, "std_tat_median_days": 3, "exp_tat_mean_hours": 35.6, "exp_tat_median_hours": 22, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.amerihealthcaritasde.com/rights/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "std_appeals_overturned is the printed 'approved after appeal' count (305 standard; 971 denied after appeal). Expedited approved after appeal: 82; denied after appeal: 10. Total appeals filed not printed separately." }, { "filing_id": "f0279", "parent_org": "Independent Health", "plan_name": "Independent Health Medicaid, Essential and CHP (combined)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 36266, "std_approved": 26040, "std_denied": 10226, "std_denial_rate": 28.2, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 191, "std_appeal_overturn_rate": null, "exp_total": 3683, "exp_approved": 3424, "exp_denied": 259, "exp_denial_rate": 7.03, "ext_review_approved": 269, "std_tat_mean_days": 2.28, "std_tat_median_days": 1, "exp_tat_mean_hours": 2.52, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.independenthealth.com/content/dam/independenthealth/individuals-and-families/my-health/prior-authorization-metrics/documents/ih-medicaid-essential-chp-plans.pdf", "source_segment": "regional", "extraction_note": "Single filing covering three distinct lines of business reported in aggregate; cannot be split." }, { "filing_id": "f0220", "parent_org": "Elevance Health", "plan_name": "Healthy Blue South Carolina (BlueChoice HealthPlan of South Carolina)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "SC", "reporting_period": "CY2025", "std_total": 55220, "std_approved": 39801, "std_denied": 15419, "std_denial_rate": 27.92, "std_denial_rate_printed": 27.9, "std_appeals_total": null, "std_appeals_overturned": 189, "std_appeal_overturn_rate": 0.34, "exp_total": 17822, "exp_approved": 15335, "exp_denied": 2487, "exp_denial_rate": 13.95, "ext_review_approved": 0, "std_tat_mean_days": 5.45, "std_tat_median_days": 5.1, "exp_tat_mean_hours": 52.8, "exp_tat_median_hours": 49.68, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.healthybluesc.com/member-center/prior-authorization", "source_segment": "w3_southeast", "extraction_note": "Page states 'Data published by March 31, 2026, covering calendar year 2025.' Expedited turnaround was printed in DAYS (avg 2.2, median 2.07) rather than hours -- unusual for an 'expedited' category, printed as-is; converted x24 to hours per schema (52.8 / 49.68) and flagged here rather than silently normalized. Table also prints an expedited 'approved after appeal' count of 277 (1.6%), for which this schema has no expedited-appeals field -- recorded here instead of std_appeals_overturned. 'Approved after extended review' was printed as 0 for both the standard and expedited pools (single ext_review_approved field used to represent both). Content is embedded directly in page HTML; no separate PDF exists. Verified with two independent fetches returning identical figures." }, { "filing_id": "f0512", "parent_org": "UnitedHealth Group", "plan_name": "UnitedHealthcare Medicare Advantage - Contract R7444", "contract_id": "R7444", "coverage_type": "Medicare Advantage", "state": null, "reporting_period": "CY2025", "std_total": 18, "std_approved": 13, "std_denied": 5, "std_denial_rate": 27.78, "std_denial_rate_printed": 27.8, "std_appeals_total": null, "std_appeals_overturned": 0, "std_appeal_overturn_rate": null, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": null, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 2.4, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicare-Advantage-2025.pdf", "source_segment": "uhc_ma", "extraction_note": "Expedited TAT printed in days; CONVERTED to hours (x24). Standard TAT as printed in days. UHC states it does not extend PA review timeframes, so no extension data exists. Mean TAT is printed as whole days beside/under the one-decimal median, so mean