{ "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": "f0068", "parent_org": "CVS Health / Aetna", "plan_name": "Aetna Better Health of New Jersey", "contract_id": "NJ-26-03-08", "coverage_type": "Medicaid Managed Care", "state": "NJ", "reporting_period": "January 1, 2025 - December 31, 2025", "std_total": 55635, "std_approved": 40306, "std_denied": 15329, "std_denial_rate": 27.55, "std_denial_rate_printed": 27.55, "std_appeals_total": 2527, "std_appeals_overturned": 380, "std_appeal_overturn_rate": 15.04, "exp_total": 11289, "exp_approved": 9780, "exp_denied": 1509, "exp_denial_rate": 13.37, "ext_review_approved": 0, "std_tat_mean_days": 8.77, "std_tat_median_days": 10, "exp_tat_mean_hours": 13.92, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/newjersey/providers/pdf/2025_ABHNJ_CMS_Web_Metrics-Provider_REM.pdf", "source_segment": "aetna_ahc", "extraction_note": "Expedited TAT printed in days (0.58 mean / 0.0 median); converted to hours x24. contract_id NJ-26-03-08 is printed on the document but may be a material-approval code rather than a payer contract number. Doc states 99.36% on-time.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NJ:aetna-better-health-nj", "filing_unit": "medicaid_plan" }, { "filing_id": "f0284", "parent_org": "Horizon Blue Cross Blue Shield of New Jersey", "plan_name": "Horizon NJ FamilyCare (Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NJ", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 17.7, "std_denial_rate_printed": 17.7, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 25.3, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 9.3, "ext_review_approved": null, "std_tat_mean_days": 7, "std_tat_median_days": 4, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 24, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.horizonblue.com/about-us/our-company/company-reports/prior-authorization-reports/cms-interoperability-prior-authorization-metrics", "source_segment": "w5_browser", "extraction_note": "Read from the live page in a browser: the three plan tables are inside collapsed accordions the crawler never opened. Horizon publishes PERCENTAGES ONLY -- no request counts anywhere -- so every count column is null rather than derived. Turnaround is printed in words ('Three (3) days'); the numerals in parentheses are what is recorded, and expedited days were converted to hours. The extended-review figure is a percentage of extended requests approved, not of all requests.", "source_sha256": null, "service_list_url": "https://www.horizonblue.com/about-us/our-company/company-reports/prior-authorization-reports/cms-interoperability-prior-authorization-metrics", "service_list_items": null, "entity_id": "mcd:NJ:horizon-nj-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0530", "parent_org": "UnitedHealth Group", "plan_name": "UnitedHealthcare Community Plan - New Jersey FamilyCare", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NJ", "reporting_period": "CY2025", "std_total": 279419, "std_approved": 236117, "std_denied": 43302, "std_denial_rate": 15.5, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 273, "std_appeal_overturn_rate": null, "exp_total": 15491, "exp_approved": 14155, "exp_denied": 1336, "exp_denial_rate": 8.62, "ext_review_approved": null, "std_tat_mean_days": 0, "std_tat_median_days": 2.2, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 14.4, "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": "national", "extraction_note": "Mean-below-median oddity.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NJ:unitedhealthcare-community-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0224", "parent_org": "Elevance Health", "plan_name": "Wellpoint New Jersey (NJ FamilyCare)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NJ", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 10.3, "std_denial_rate_printed": 10.3, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 41.6, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 7, "ext_review_approved": null, "std_tat_mean_days": 5, "std_tat_median_days": 1, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 24, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.wellpoint.com/content/dam/digital/wellpoint/documents/medicaid/new-jersey/nj_medicaid_chip_priorauthsmetrics.pdf", "source_segment": "wave2", "extraction_note": "Percentages only; combined Medicaid and CHIP book.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NJ:amerigroup-new-jersey", "filing_unit": "medicaid_plan" } ] }