{ "meta": { "total": 12, "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": "f0364", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Texas", "contract_id": "20069", "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 22.71, "std_denial_rate_printed": 22.71, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 50.55, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 30.33, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 0.4, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 48, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://assets.ctfassets.net/plyq12u1bv8a/2eqNqyzHXh6XEXERmy6twp/4b4b73812a644ef1ab14f10f5b9621dd/PY2025_TX_20069.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. Highest standard denial rate in Oscar's 12-state set." }, { "filing_id": "f0356", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Michigan", "contract_id": "77739", "coverage_type": "Marketplace QHP", "state": "MI", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 20.45, "std_denial_rate_printed": 20.45, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 73.33, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 24.55, "ext_review_approved": null, "std_tat_mean_days": 4.8, "std_tat_median_days": 3.7, "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://assets.ctfassets.net/plyq12u1bv8a/5CYGdnu4eZUwZo9CjhkwVf/5c117862279f37594a00f4866ee49a9e/PY2025_MI_77739.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only; the '% Total Requests' row is present in the template but left blank." }, { "filing_id": "f0353", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Arizona", "contract_id": "13877", "coverage_type": "Marketplace QHP", "state": "AZ", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 18.89, "std_denial_rate_printed": 18.89, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 44.83, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 24.85, "ext_review_approved": null, "std_tat_mean_days": 4.1, "std_tat_median_days": 1.7, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 48, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://assets.ctfassets.net/plyq12u1bv8a/4blI9BzOdVduDfKhqmkj43/95b177dfe5b9075b16be586732522609/PY2025_AZ_13877.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only; denominator not disclosed. Caution: an automated read can misread the HIOS plan ID as a request count." }, { "filing_id": "f0362", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Oklahoma", "contract_id": "91908", "coverage_type": "Marketplace QHP", "state": "OK", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 18.46, "std_denial_rate_printed": 18.46, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 100, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 25, "ext_review_approved": null, "std_tat_mean_days": 2.9, "std_tat_median_days": 1.4, "exp_tat_mean_hours": 43.2, "exp_tat_median_hours": 21.6, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://assets.ctfassets.net/plyq12u1bv8a/4fbNDkDzvbQsg0jlPyE4C4/28f0ee0a1050bd13a06e61d2d592d7b3/PY2025_OK_91908.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. Standard appeal overturn printed as 100% with no denominator disclosed." }, { "filing_id": "f0361", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Ohio (issuer 45845)", "contract_id": "45845", "coverage_type": "Marketplace QHP", "state": "OH", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 18.4, "std_denial_rate_printed": 18.4, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 63.33, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 28.81, "ext_review_approved": null, "std_tat_mean_days": 2.4, "std_tat_median_days": 0.5, "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://assets.ctfassets.net/plyq12u1bv8a/4wHOBuduXnIvTkrd6Ptt0w/3401874ed86fda1d6187286e2a6aa6b1/PY2025_OH_45845.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only." }, { "filing_id": "f0354", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Iowa", "contract_id": "45819", "coverage_type": "Marketplace QHP", "state": "IA", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 17.62, "std_denial_rate_printed": 17.62, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 33.87, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 42.52, "ext_review_approved": null, "std_tat_mean_days": 3.8, "std_tat_median_days": 2, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 48, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://assets.ctfassets.net/plyq12u1bv8a/3b7sTgdh0fdvP9KkBPhbmh/fd034349be62cd673533fa07d16868f0/PY2025_IA_45819.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only, no counts." }, { "filing_id": "f0359", "parent_org": "Oscar Health", "plan_name": "Oscar Health - North Carolina", "contract_id": "69803", "coverage_type": "Marketplace QHP", "state": "NC", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 17.07, "std_denial_rate_printed": 17.07, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 43.75, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 34.72, "ext_review_approved": null, "std_tat_mean_days": 2.1, "std_tat_median_days": 0.8, "exp_tat_mean_hours": 45.6, "exp_tat_median_hours": 45.6, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://assets.ctfassets.net/plyq12u1bv8a/1fkV71FL93mQm1Dm31zQi5/327fb8824a9a399db674ad831391303e/PY2025_NC_69803.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. Expedited turnaround (1.9 days) is slower than standard, as printed." }, { "filing_id": "f0358", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Nebraska", "contract_id": "57424", "coverage_type": "Marketplace QHP", "state": "NE", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 16.77, "std_denial_rate_printed": 16.77, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 50, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 37.89, "ext_review_approved": null, "std_tat_mean_days": 3.6, "std_tat_median_days": 2.3, "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://assets.ctfassets.net/plyq12u1bv8a/1A8M7XlqEVAH6SAJTP5ZiL/58a956f620b06bc7346e018753561f1b/PY2025_NE_57424.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. Expedited appeal overturn printed as 100% with no disclosed denominator." }, { "filing_id": "f0360", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Ohio (issuer 29341)", "contract_id": "29341", "coverage_type": "Marketplace QHP", "state": "OH", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 16.62, "std_denial_rate_printed": 16.62, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 50, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 33.52, "ext_review_approved": null, "std_tat_mean_days": 1.6, "std_tat_median_days": 0.3, "exp_tat_mean_hours": 26.4, "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://assets.ctfassets.net/plyq12u1bv8a/5YZJo8nvmHrnfzLYGc6So8/a9c22d4355116a223ce5d551b86ce0a5/PY2025_OH_29341.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. Oscar files two separate Ohio issuer IDs." }, { "filing_id": "f0357", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Missouri", "contract_id": "69512", "coverage_type": "Marketplace QHP", "state": "MO", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 16.1, "std_denial_rate_printed": 16.1, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 50, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 33.17, "ext_review_approved": null, "std_tat_mean_days": 2.2, "std_tat_median_days": 0.2, "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://assets.ctfassets.net/plyq12u1bv8a/1ndGAtpoZRaejT1qMr18VR/ee4006452621a52b838ce6a303cf4ee4/PY2025_MO_69512.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. Standard median of 0.2 days is far below the 2.2-day mean, as printed." }, { "filing_id": "f0355", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Kansas", "contract_id": "43490", "coverage_type": "Marketplace QHP", "state": "KS", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 13.96, "std_denial_rate_printed": 13.96, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 48.39, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 27.79, "ext_review_approved": null, "std_tat_mean_days": 4.1, "std_tat_median_days": 1.9, "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://assets.ctfassets.net/plyq12u1bv8a/4fY2AdTH87b1AilWzMnDAF/4de099966db939d71039dbc91088608b/PY2025_KS_43490.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only. An automated read returned 'Prior Authorization Requests: 43,490' - that is the HIOS plan ID, not a count." }, { "filing_id": "f0363", "parent_org": "Oscar Health", "plan_name": "Oscar Health - Tennessee", "contract_id": "23552", "coverage_type": "Marketplace QHP", "state": "TN", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 11.89, "std_denial_rate_printed": 11.89, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 47.41, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 26.66, "ext_review_approved": null, "std_tat_mean_days": 2.3, "std_tat_median_days": 0.7, "exp_tat_mean_hours": 21.6, "exp_tat_median_hours": 21.6, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://assets.ctfassets.net/plyq12u1bv8a/1ddRMANcB5i2BcR8rc8Nom/4f229a8c35b54e64010b83cc23d3df0d/PY2025_TN_23552.pdf", "source_segment": "marketplace", "extraction_note": "Percentages only." } ] }