{ "meta": { "total": 3, "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": "f0394", "parent_org": "Texas Children's Health Plan", "plan_name": "Texas Children's Health Plan (STAR/CHIP/STAR Kids combined)", "contract_id": null, "coverage_type": "Multiple (combined)", "state": "TX", "reporting_period": "2025", "std_total": 128038, "std_approved": 115340, "std_denied": 12698, "std_denial_rate": 9.92, "std_denial_rate_printed": 9.9, "std_appeals_total": 2740, "std_appeals_overturned": 1042, "std_appeal_overturn_rate": 38.03, "exp_total": 4867, "exp_approved": 4601, "exp_denied": 266, "exp_denial_rate": 5.47, "ext_review_approved": 7574, "std_tat_mean_days": null, "std_tat_median_days": null, "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.texaschildrenshealthplan.org/sites/default/files/2026-03/MK-2603-539%20PRIOR%20AUTHORIZATION%20PDF%20%28With%20Metrics%29.pdf", "source_segment": "w3_tx_south", "extraction_note": "Document reports one set of figures for the whole plan without differentiating STAR, CHIP, and STAR Kids lines, hence coverage_type Multiple (combined). ext_review_approved holds the standard-track figure (7,574 of a subset, 5.9%); the document also prints an expedited extended-review figure of 15 (0.3%) that has no schema field and is noted here only. Expedited appeals (16 of 57 overturned, 28.1%) likewise have no dedicated schema field (only std_appeals_* exist) and are noted here rather than dropped. Standard turnaround printed as 2.5 (mean) / 2 (median) and expedited as 0.5 (mean) / 0 (median) with NO unit label anywhere in the document -- only response-window text (7 calendar days standard, 72 hours expedited) appears near the numbers. Unit could not be established from context, so all four TAT fields are left null per the no-guessing rule." }, { "filing_id": "f0256", "parent_org": "HealthPartners", "plan_name": "HealthPartners Medicare Advantage and Minnesota Senior Health Options (MSHO), combined", "contract_id": null, "coverage_type": "Multiple (combined)", "state": "MN", "reporting_period": "CY2025 (January 1, 2025 - December 31, 2025)", "std_total": 11994, "std_approved": 11241, "std_denied": 753, "std_denial_rate": 6.28, "std_denial_rate_printed": 6, "std_appeals_total": 203, "std_appeals_overturned": 175, "std_appeal_overturn_rate": 86.21, "exp_total": 1151, "exp_approved": 1082, "exp_denied": 69, "exp_denial_rate": 5.99, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 0, "exp_tat_mean_hours": 7.72, "exp_tat_median_hours": 0.09, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.healthpartners.com/content/dam/corporate/integrity-compliance/pa-reporting-cy2025-ma-medadv-msho-indwionexch.pdf", "source_segment": "w3_midwest", "extraction_note": "Document combines standard Medicare Advantage with Minnesota Senior Health Options (MSHO, a Medicare-Medicaid dual-eligible integrated plan) into one reporting line and cannot be split from what was extracted -- coverage_type set to 'Multiple (combined)' per brief guidance since MSHO would otherwise be 'Medicare-Medicaid Plan' and general MA is 'Medicare Advantage'. Expedited appeals reported separately (22 total, 15 overturned) but no exp_appeals field exists in this schema; noted here only." }, { "filing_id": "f0026", "parent_org": "Blue Cross & Blue Shield of Rhode Island", "plan_name": "Blue Cross & Blue Shield of Rhode Island (all impacted lines combined)", "contract_id": null, "coverage_type": "Multiple (combined)", "state": "RI", "reporting_period": "CY2025", "std_total": 68179, "std_approved": 64815, "std_denied": 3364, "std_denial_rate": 4.93, "std_denial_rate_printed": 4.93, "std_appeals_total": null, "std_appeals_overturned": 708, "std_appeal_overturn_rate": null, "exp_total": 6701, "exp_approved": 6431, "exp_denied": 270, "exp_denial_rate": 4.03, "ext_review_approved": 0, "std_tat_mean_days": 1, "std_tat_median_days": null, "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.bcbsri.com/sitefiles/bcbsri-interoperability-metrics", "source_segment": "blues", "extraction_note": "coverage_type does NOT fit the required enum: BCBSRI publishes ONE combined set of figures spanning MA, Medicaid managed care, CHIP managed care and QHP business, with no per-plan or per-contract breakout, so the value is recorded as 'Multiple (combined)' rather than guessing a single line of business. Only the appeal OVERTURN count is published (708 approved after appeal); no appeal denominator, so std_appeals_total and overturn pct are null. Median standard TAT and both expedited TATs are printed as '<1 day' and are therefore null; standard mean is printed as '1 day'." } ] }