{ "meta": { "total": 4, "page": 1, "per_page": 50, "pages": 1, "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": "f0282", "parent_org": "Highmark", "plan_name": "Highmark QHP (federal Marketplace) - West Virginia", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "WV", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": 25350, "std_approved": 22352, "std_denied": 2998, "std_denial_rate": 11.83, "std_denial_rate_printed": 12, "std_appeals_total": 20, "std_appeals_overturned": 7, "std_appeal_overturn_rate": 35, "exp_total": 6408, "exp_approved": 5806, "exp_denied": 602, "exp_denial_rate": 9.39, "ext_review_approved": null, "std_tat_mean_days": 0.41, "std_tat_median_days": 0, "exp_tat_mean_hours": 13.44, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf", "source_segment": "blues", "extraction_note": "Expedited decision time was published in DAYS and converted to hours (x24); standard TAT left in days as published. No standard extended-review figures printed for the QHP rows. Expedited appeals: 9 total, 2 approved. Standard approval rate (88%) is the lowest of Highmark's four QHP markets.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:WV:31274", "filing_unit": "qhp_issuer" }, { "filing_id": "f0279", "parent_org": "Highmark", "plan_name": "Highmark QHP (federal Marketplace) - Delaware", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "DE", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": 16283, "std_approved": 14939, "std_denied": 1344, "std_denial_rate": 8.25, "std_denial_rate_printed": 8, "std_appeals_total": 5, "std_appeals_overturned": 3, "std_appeal_overturn_rate": 60, "exp_total": 3343, "exp_approved": 3056, "exp_denied": 287, "exp_denial_rate": 8.59, "ext_review_approved": null, "std_tat_mean_days": 0.68, "std_tat_median_days": 0, "exp_tat_mean_hours": 12.24, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf", "source_segment": "blues", "extraction_note": "Expedited decision time was published in DAYS and converted to hours (x24); standard TAT left in days as published. No standard extended-review figures printed for the QHP rows. Expedited extended review 1 total / 1 approved. Expedited appeals: 7 total, 3 approved.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:DE:76168", "filing_unit": "qhp_issuer" }, { "filing_id": "f0281", "parent_org": "Highmark", "plan_name": "Highmark QHP (federal Marketplace) - Pennsylvania", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "PA", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": 77677, "std_approved": 72961, "std_denied": 4716, "std_denial_rate": 6.07, "std_denial_rate_printed": 6, "std_appeals_total": 50, "std_appeals_overturned": 27, "std_appeal_overturn_rate": 54, "exp_total": 13598, "exp_approved": 12455, "exp_denied": 1143, "exp_denial_rate": 8.41, "ext_review_approved": null, "std_tat_mean_days": 0.43, "std_tat_median_days": 0, "exp_tat_mean_hours": 11.76, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf", "source_segment": "blues", "extraction_note": "Expedited decision time was published in DAYS and converted to hours (x24); standard TAT left in days as published. No standard extended-review figures printed for the QHP rows. Expedited extended review 18 total / 17 approved / 1 denied. Expedited appeals: 16 total, 4 approved. Only 50 standard appeals against 4,716 denials.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0280", "parent_org": "Highmark", "plan_name": "Highmark QHP (federal Marketplace) - New York", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "NY", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": 1342, "std_approved": 1296, "std_denied": 46, "std_denial_rate": 3.43, "std_denial_rate_printed": null, "std_appeals_total": 0, "std_appeals_overturned": 0, "std_appeal_overturn_rate": null, "exp_total": 165, "exp_approved": 148, "exp_denied": 17, "exp_denial_rate": 10.3, "ext_review_approved": null, "std_tat_mean_days": 0.87, "std_tat_median_days": 0, "exp_tat_mean_hours": 12.48, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf", "source_segment": "blues", "extraction_note": "Expedited decision time was published in DAYS and converted to hours (x24); standard TAT left in days as published. No standard extended-review figures printed for the QHP rows. Zero standard appeals reported. Standard denied percentage not printed.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null } ] }