{ "meta": { "total": 6, "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": "f0140", "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.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:TX:29418", "filing_unit": "qhp_issuer" }, { "filing_id": "f0141", "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.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:TX:87226", "filing_unit": "qhp_issuer" }, { "filing_id": "f0437", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Texas", "contract_id": "20069", "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 22.71, "std_denial_rate_printed": 22.71, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 50.55, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 30.33, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 0.4, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 48, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://assets.ctfassets.net/plyq12u1bv8a/2eqNqyzHXh6XEXERmy6twp/4b4b73812a644ef1ab14f10f5b9621dd/PY2025_TX_20069.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. Highest standard denial rate in Oscar's 12-state set.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:TX:20069", "filing_unit": "qhp_issuer" }, { "filing_id": "christus-pc2658", "parent_org": "CHRISTUS Health", "plan_name": "CHRISTUS Health Plan (TX Marketplace)", "contract_id": "PC2658", "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": 2816, "std_approved": 2680, "std_denied": 136, "std_denial_rate": 4.83, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 1, "std_appeal_overturn_rate": 12, "exp_total": 514, "exp_approved": 494, "exp_denied": 20, "exp_denial_rate": 3.89, "ext_review_approved": null, "std_tat_mean_days": 3.4, "std_tat_median_days": 3, "exp_tat_mean_hours": 52.8, "exp_tat_median_hours": 48, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://chppayment.christushealth.org/documents/2026/General/TX%20HIX%20Determination%20statistics_PC2658.pdf", "source_segment": "filings_2025", "extraction_note": null, "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:TX:66252", "filing_unit": "qhp_issuer" }, { "filing_id": "cfhp-marketplace", "parent_org": "Community First Health Plans", "plan_name": "University Community Care Plan (Marketplace)", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": 2726, "std_approved": 2631, "std_denied": 76, "std_denial_rate": 2.79, "std_denial_rate_printed": null, "std_appeals_total": 9, "std_appeals_overturned": 6, "std_appeal_overturn_rate": 66.67, "exp_total": 499, "exp_approved": 358, "exp_denied": 28, "exp_denial_rate": 5.61, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 2, "exp_tat_mean_hours": 40.1, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://exchange.communityfirsthealthplans.com/wp-content/uploads/sites/4/2026/03/2025-Prior-Authorization-Metrics-for-Medical-Items-Services-Excluding-Drugs.pdf", "source_segment": "filings_2025", "extraction_note": null, "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:TX:63251", "filing_unit": "qhp_issuer" }, { "filing_id": "f0471", "parent_org": "Sendero Health Plans", "plan_name": "Sendero Health Plans (IdealCare marketplace)", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": null, "std_approved": 8659, "std_denied": 188, "std_denial_rate": 2.17, "std_denial_rate_printed": 2.17, "std_appeals_total": 28, "std_appeals_overturned": 14, "std_appeal_overturn_rate": 50, "exp_total": null, "exp_approved": 1304, "exp_denied": 16, "exp_denial_rate": 1.23, "ext_review_approved": null, "std_tat_mean_days": 2.4, "std_tat_median_days": 1.46, "exp_tat_mean_hours": 18.8, "exp_tat_median_hours": 16, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://senderohealth.com/files/2025%20PA%20Stats%20and%20Summary%20-%20APPROVALS%20-%20DENIALS%20-%20APPEALS.pdf", "source_segment": "marketplace", "extraction_note": "Month-by-month table with no total-requests denominator, so totals are null. Narrative text conflates the approvals column total with requests received. Standard TAT printed in HOURS and converted to days.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:TX:71837", "filing_unit": "qhp_issuer" } ] }