{ "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": "f0045", "parent_org": "Blue Cross and Blue Shield of North Carolina", "plan_name": "Blue Cross NC ACA (Marketplace) plans", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "NC", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 17.54, "std_denial_rate_printed": 17.54, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 47.27, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 11.8, "ext_review_approved": null, "std_tat_mean_days": 2.16, "std_tat_median_days": 1, "exp_tat_mean_hours": 34.49, "exp_tat_median_hours": 20.47, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.bcbsnc.com/providers/prior-authorization/metrics", "source_segment": "blues", "extraction_note": "Page publishes PERCENTAGES ONLY - no raw request counts or denominators disclosed; confirmed on a second targeted fetch. No contract IDs published. Page last updated 3/31/2026. 'Appealed & approved' column interpreted as appeal overturn rate. Timelines stated in business days for ACA. Extended review reported as 0%.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0047", "parent_org": "Blue Cross and Blue Shield of North Carolina", "plan_name": "Experience Health Medicare Advantage (HMO)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "NC", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 3.92, "std_denial_rate_printed": 3.92, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 66.67, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 9.82, "ext_review_approved": null, "std_tat_mean_days": 5, "std_tat_median_days": 3, "exp_tat_mean_hours": 16.07, "exp_tat_median_hours": 8.3, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.bcbsnc.com/providers/prior-authorization/metrics", "source_segment": "blues", "extraction_note": "Page publishes PERCENTAGES ONLY - no raw request counts or denominators disclosed; confirmed on a second targeted fetch. No contract IDs published. Page last updated 3/31/2026. 'Appealed & approved' column interpreted as appeal overturn rate. Extended review reported N/A.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3777", "filing_unit": "ma_contract" }, { "filing_id": "f0046", "parent_org": "Blue Cross and Blue Shield of North Carolina", "plan_name": "Blue Medicare Advantage (PPO)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "NC", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 2.98, "std_denial_rate_printed": 2.98, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 74.24, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 2.83, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 2, "exp_tat_mean_hours": 16.07, "exp_tat_median_hours": 8.62, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.bcbsnc.com/providers/prior-authorization/metrics", "source_segment": "blues", "extraction_note": "Page publishes PERCENTAGES ONLY - no raw request counts or denominators disclosed; confirmed on a second targeted fetch. No contract IDs published. Page last updated 3/31/2026. 'Appealed & approved' column interpreted as appeal overturn rate. Extended review reported N/A.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3449", "filing_unit": "ma_contract" }, { "filing_id": "f0048", "parent_org": "Blue Cross and Blue Shield of North Carolina", "plan_name": "Healthy Blue + Medicare (HMO-POS D-SNP)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "NC", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 2.7, "std_denial_rate_printed": 2.7, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 86.1, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 1.5, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 24, "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.bcbsnc.com/providers/prior-authorization/metrics", "source_segment": "blues", "extraction_note": "Page publishes PERCENTAGES ONLY - no raw request counts or denominators disclosed; confirmed on a second targeted fetch. No contract IDs published. Page last updated 3/31/2026. 'Appealed & approved' column interpreted as appeal overturn rate. D-SNP. Extended review reported N/A.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3449", "filing_unit": "ma_contract" } ] }