{ "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": "f0310", "parent_org": "Martin's Point Health Care", "plan_name": "Generations Advantage LPPO - Medical (non-oncology)", "contract_id": "H1365", "coverage_type": "Medicare Advantage", "state": "ME", "reporting_period": "CY2025", "std_total": 568, "std_approved": 500, "std_denied": 68, "std_denial_rate": 11.97, "std_denial_rate_printed": null, "std_appeals_total": 158, "std_appeals_overturned": 98, "std_appeal_overturn_rate": 62.03, "exp_total": 145, "exp_approved": 128, "exp_denied": 17, "exp_denial_rate": 11.72, "ext_review_approved": 0, "std_tat_mean_days": 7, "std_tat_median_days": 8, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://martinspoint.org/-/media/Files/compliance/prior-auth-report.pdf", "source_segment": "regional", "extraction_note": "Appeals figures identical to H5591 - almost certainly a combined two-contract number, not contract-level." }, { "filing_id": "f0307", "parent_org": "Martin's Point Health Care", "plan_name": "Generations Advantage HMO - Medical (non-oncology)", "contract_id": "H5591", "coverage_type": "Medicare Advantage", "state": "ME", "reporting_period": "CY2025", "std_total": 7943, "std_approved": 7346, "std_denied": 597, "std_denial_rate": 7.52, "std_denial_rate_printed": null, "std_appeals_total": 158, "std_appeals_overturned": 98, "std_appeal_overturn_rate": 62.03, "exp_total": 2104, "exp_approved": 1967, "exp_denied": 137, "exp_denial_rate": 6.51, "ext_review_approved": 0, "std_tat_mean_days": 7, "std_tat_median_days": 8, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 72, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://martinspoint.org/-/media/Files/compliance/prior-auth-report.pdf", "source_segment": "regional", "extraction_note": "Filing splits by service category. Standard median (8d) exceeds mean (7d); expedited median (72h) exceeds mean (24h) and the 72-hour standard. Appeals figures identical to H1365, likely a shared number." }, { "filing_id": "f0308", "parent_org": "Martin's Point Health Care", "plan_name": "Generations Advantage HMO - Optum oncology/radiology", "contract_id": "H5591", "coverage_type": "Medicare Advantage", "state": "ME", "reporting_period": "CY2025", "std_total": 6655, "std_approved": 6326, "std_denied": 329, "std_denial_rate": 4.94, "std_denial_rate_printed": null, "std_appeals_total": 41, "std_appeals_overturned": 33, "std_appeal_overturn_rate": 80.49, "exp_total": 56, "exp_approved": 48, "exp_denied": 8, "exp_denial_rate": 14.29, "ext_review_approved": null, "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://martinspoint.org/-/media/Files/compliance/prior-auth-report.pdf", "source_segment": "regional", "extraction_note": "Delegated-vendor segment. TAT published per sub-program and cannot be collapsed; this vendor reports STANDARD turnaround in hours, unlike the rest of the filing." }, { "filing_id": "f0311", "parent_org": "Martin's Point Health Care", "plan_name": "Generations Advantage LPPO - Optum oncology/radiology", "contract_id": "H1365", "coverage_type": "Medicare Advantage", "state": "ME", "reporting_period": "CY2025", "std_total": 387, "std_approved": 376, "std_denied": 11, "std_denial_rate": 2.84, "std_denial_rate_printed": null, "std_appeals_total": 4, "std_appeals_overturned": 3, "std_appeal_overturn_rate": 75, "exp_total": 4, "exp_approved": 4, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": null, "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://martinspoint.org/-/media/Files/compliance/prior-auth-report.pdf", "source_segment": "regional", "extraction_note": "Delegated-vendor segment; TAT published per sub-program in hours, not collapsed." }, { "filing_id": "f0306", "parent_org": "Martin's Point Health Care", "plan_name": "Generations Advantage HMO - Behavioral Health", "contract_id": "H5591", "coverage_type": "Medicare Advantage", "state": "ME", "reporting_period": "CY2025", "std_total": 131, "std_approved": 131, "std_denied": 0, "std_denial_rate": 0, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 166, "exp_approved": 154, "exp_denied": 12, "exp_denial_rate": 7.23, "ext_review_approved": null, "std_tat_mean_days": 7, "std_tat_median_days": 2, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "info:appeals_not_reported; warn:expedited_exceeds_standard_volume; warn:zero_denial_rate", "error_count": 0, "warn_count": 2, "source_url": "https://martinspoint.org/-/media/Files/compliance/prior-auth-report.pdf", "source_segment": "regional", "extraction_note": "Behavioral health segment only." }, { "filing_id": "f0309", "parent_org": "Martin's Point Health Care", "plan_name": "Generations Advantage LPPO - Behavioral Health", "contract_id": "H1365", "coverage_type": "Medicare Advantage", "state": "ME", "reporting_period": "CY2025", "std_total": 17, "std_approved": 17, "std_denied": 0, "std_denial_rate": 0, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 8, "exp_approved": 7, "exp_denied": 1, "exp_denial_rate": 12.5, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "info:appeals_not_reported; warn:zero_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://martinspoint.org/-/media/Files/compliance/prior-auth-report.pdf", "source_segment": "regional", "extraction_note": "Behavioral health segment; very small volumes." } ] }