{ "meta": { "total": 536, "page": 1, "per_page": 5, "pages": 108, "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": "f0527", "parent_org": "VillageCare", "plan_name": "VillageCareMAX Managed Long-Term Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 62.3, "std_denial_rate_printed": 62.3, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 4.3, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 46.6, "ext_review_approved": null, "std_tat_mean_days": 7.28, "std_tat_median_days": 5, "exp_tat_mean_hours": 92.64, "exp_tat_median_hours": 24, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.villagecaremax.org/prior-authorizations-reporting", "source_segment": "ca_ny", "extraction_note": "HIGHEST DENIAL RATE IN THE DATASET: 62.3% standard, 46.6% expedited. Only 4.3% of appeals overturned. Expedited mean of 3.86 days (92.6h) far exceeds any expedited standard. Percentages only, no counts to check against." }, { "filing_id": "f0250", "parent_org": "Hamaspik", "plan_name": "Hamaspik Medicare Choice (MAP - Medicaid side)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 52, "std_denial_rate_printed": 52, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 8, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 7.84, "std_tat_median_days": 3.59, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.hamaspik.com/priorauthdata?hsLang=en", "source_segment": "w3_ky_nc_ms_ny", "extraction_note": "MAP = Medicaid Advantage Plus; this column is the Medicaid-side reporting for Hamaspik's dual-eligible integrated plan (the Medicare-side is reported separately as 'Hamaspik Medicare Select'). Expedited approved and denied are BOTH printed as 0%, and no expedited turnaround time is shown at all - this most likely reflects zero expedited-request volume for this plan rather than a measured 0% denial rate; recorded as printed, flagged rather than omitted or treated as null. Percentages only, no counts. 'Extended timeframe approved' (9%) not stored - field expects a count." }, { "filing_id": "f0249", "parent_org": "Hamaspik", "plan_name": "Hamaspik Choice (MLTC)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 49, "std_denial_rate_printed": 49, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 15, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 16, "ext_review_approved": null, "std_tat_mean_days": 7.59, "std_tat_median_days": 4.28, "exp_tat_mean_hours": 101.28, "exp_tat_median_hours": 61.44, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.hamaspik.com/priorauthdata?hsLang=en", "source_segment": "w3_ky_nc_ms_ny", "extraction_note": "Source page's turnaround table header labels both standard and expedited columns '(days)'; expedited mean/median (4.22d / 2.56d as printed) were converted to hours (101.28 / 61.44). Percentages only ('aggregated for all items & services'), no total request counts published. Page's 'Extended timeframe approved' figure (15%) not stored - field expects a count, not a percentage." }, { "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": "f0403", "parent_org": "UCare", "plan_name": "Prepaid Medical Assistance Program (PMAP)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MN", "reporting_period": "CY2025", "std_total": 30736, "std_approved": 16043, "std_denied": 14693, "std_denial_rate": 47.8, "std_denial_rate_printed": null, "std_appeals_total": 850, "std_appeals_overturned": 113, "std_appeal_overturn_rate": 13.29, "exp_total": 469, "exp_approved": 356, "exp_denied": 113, "exp_denial_rate": 24.09, "ext_review_approved": 0, "std_tat_mean_days": 6, "std_tat_median_days": 8, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "warn:high_denial_rate", "error_count": 0, "warn_count": 1, "source_url": "https://ucm-p-001.sitecorecontenthub.cloud/api/public/content/U15479_PAMetricsReport__PMAP_2026.pdf", "source_segment": "sweep", "extraction_note": "Mean standard TAT (6 days) is below the median (8 days)." } ] }