{ "meta": { "total": 8, "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": "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": "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": "f0025", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "Keystone First CHIP", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "PA", "reporting_period": "CY2025", "std_total": 4394, "std_approved": 3507, "std_denied": 874, "std_denial_rate": 19.89, "std_denial_rate_printed": 19.9, "std_appeals_total": null, "std_appeals_overturned": 12, "std_appeal_overturn_rate": null, "exp_total": 22, "exp_approved": 21, "exp_denied": 1, "exp_denial_rate": 4.55, "ext_review_approved": null, "std_tat_mean_days": 4.1, "std_tat_median_days": 2, "exp_tat_mean_hours": 56.73, "exp_tat_median_hours": 27, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.keystonefirstchip.com/enrollees/rights/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "Expedited appeals overturned: 0. Extended review published as a percentage only (0.4% standard, 0% expedited). RECONCILIATION FLAG: 3,507 + 874 = 4,381 vs printed total 4,394. Expedited mean TAT (56.73 hours) is more than double the expedited median (27 hours)." }, { "filing_id": "f0020", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "AmeriHealth Caritas District of Columbia", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "DC", "reporting_period": "CY2025", "std_total": 99165, "std_approved": 80119, "std_denied": 18953, "std_denial_rate": 19.11, "std_denial_rate_printed": 19.11, "std_appeals_total": null, "std_appeals_overturned": 148, "std_appeal_overturn_rate": null, "exp_total": 1175, "exp_approved": 1085, "exp_denied": 87, "exp_denial_rate": 7.4, "ext_review_approved": null, "std_tat_mean_days": 0.72, "std_tat_median_days": 1, "exp_tat_mean_hours": 8.37, "exp_tat_median_hours": 3, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.amerihealthcaritasdc.com/member/medicaid/information/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "std_appeals_overturned is the printed 'approved after appeal' count; total appeals filed not printed. Expedited approved after appeal: 5. Approved other than requested: 93 standard, 3 expedited. Extended review published as a percentage only (0.3% standard, 0.1% expedited). Printed approval rates: 80.79% standard, 92.34% expedited." }, { "filing_id": "f0021", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "AmeriHealth Caritas New Hampshire", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NH", "reporting_period": "CY2025", "std_total": 17385, "std_approved": 13815, "std_denied": 3265, "std_denial_rate": 18.78, "std_denial_rate_printed": 18.78, "std_appeals_total": null, "std_appeals_overturned": 316, "std_appeal_overturn_rate": null, "exp_total": 934, "exp_approved": 778, "exp_denied": 129, "exp_denial_rate": 13.81, "ext_review_approved": null, "std_tat_mean_days": 5.74, "std_tat_median_days": 6, "exp_tat_mean_hours": 49.95, "exp_tat_median_hours": 32, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://www.amerihealthcaritasnh.com/member/rights/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "Expedited appeals overturned: 12. Extended review reported as a percentage only (standard 1.6%, expedited 0%), so ext_review_approved is null. Approved-other-than-requested: 305 standard (1.75%), 27 expedited (2.89%). RECONCILIATION FLAG: 13,815 + 3,265 = 17,080 vs printed total 17,385." }, { "filing_id": "f0024", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "First Choice by Select Health of South Carolina", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "SC", "reporting_period": "CY2025", "std_total": 72229, "std_approved": 57563, "std_denied": 13195, "std_denial_rate": 18.27, "std_denial_rate_printed": 18.3, "std_appeals_total": null, "std_appeals_overturned": 944, "std_appeal_overturn_rate": null, "exp_total": 2123, "exp_approved": 1823, "exp_denied": 294, "exp_denial_rate": 13.85, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 1, "exp_tat_mean_hours": 15.83, "exp_tat_median_hours": 20, "reports_counts": true, "quality_flags": "error:std_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://www.selecthealthofsc.com/member/info-for-you/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "Expedited appeals overturned: 47. Extended review published as a percentage only (standard 0.01%, expedited 0%), so ext_review_approved is null. Approved other than requested: 1,471 standard, 6 expedited. RECONCILIATION FLAG: 57,563 + 13,195 = 70,758 vs printed total 72,229. Expedited mean TAT (15.83 h) is shorter than the printed 20-hour median." }, { "filing_id": "f0023", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "AmeriHealth Caritas VIP Care (Pennsylvania)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "PA", "reporting_period": "CY2025", "std_total": 25190, "std_approved": 20799, "std_denied": 4323, "std_denial_rate": 17.16, "std_denial_rate_printed": 17.16, "std_appeals_total": null, "std_appeals_overturned": 120, "std_appeal_overturn_rate": null, "exp_total": 923, "exp_approved": 716, "exp_denied": 207, "exp_denial_rate": 22.43, "ext_review_approved": null, "std_tat_mean_days": 3.65, "std_tat_median_days": 2, "exp_tat_mean_hours": 33.7, "exp_tat_median_hours": 25, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.amerihealthcaritasvipcare.com/pa/member-2026/resources/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "D-SNP product, classified Medicare Advantage. Expedited appeals overturned: 5. Extended review published as a percentage of approved requests (standard 0.3%, expedited 0.1%), so ext_review_approved is null. RECONCILIATION FLAG: 20,799 + 4,323 = 25,122 vs printed total 25,190." }, { "filing_id": "f0022", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "AmeriHealth Caritas VIP Care (Michigan)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "MI", "reporting_period": "CY2025", "std_total": 5602, "std_approved": 4675, "std_denied": 921, "std_denial_rate": 16.44, "std_denial_rate_printed": 16.44, "std_appeals_total": null, "std_appeals_overturned": 125, "std_appeal_overturn_rate": null, "exp_total": 521, "exp_approved": 452, "exp_denied": 64, "exp_denial_rate": 12.28, "ext_review_approved": null, "std_tat_mean_days": 3.98, "std_tat_median_days": 3, "exp_tat_mean_hours": 21.93, "exp_tat_median_hours": 22, "reports_counts": true, "quality_flags": "error:exp_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://www.amerihealthcaritasvipcare.com/mi/member-2026/resources/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "D-SNP product (VIP Care Plus lineage), classified Medicare Advantage. Expedited appeals overturned: 7. Extended review published as a percentage only (0.1% standard, 0% expedited). RECONCILIATION FLAG: 4,675 + 921 = 5,596 vs printed total 5,602. Printed overall approval rates: 83.45% standard, 86.76% expedited." } ] }