{ "meta": { "total": 23, "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": "f0016", "parent_org": "AmeriHealth Caritas", "plan_name": "Keystone First", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "PA", "reporting_period": "CY2025", "std_total": 314611, "std_approved": 234056, "std_denied": 89408, "std_denial_rate": 28.42, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 792, "std_appeal_overturn_rate": null, "exp_total": 1933, "exp_approved": 1523, "exp_denied": 410, "exp_denial_rate": 21.21, "ext_review_approved": null, "std_tat_mean_days": 4.8, "std_tat_median_days": 2, "exp_tat_mean_hours": 66.87, "exp_tat_median_hours": 17, "reports_counts": true, "quality_flags": "error:std_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://www.keystonefirstpa.com/member/rights/prior-authorization-reporting", "source_segment": "states", "extraction_note": "INTERNAL INCONSISTENCY: percentages sum to 102.8%, and 234,056 + 89,408 = 323,464 EXCEEDS the stated total of 314,611." }, { "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": "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." }, { "filing_id": "f0366", "parent_org": "Point32Health", "plan_name": "Harvard Pilgrim Health Care – New Hampshire Exchange Local Choice", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "NH", "reporting_period": "CY2025", "std_total": 182, "std_approved": 150, "std_denied": 29, "std_denial_rate": 15.93, "std_denial_rate_printed": 15.9, "std_appeals_total": null, "std_appeals_overturned": 0, "std_appeal_overturn_rate": null, "exp_total": 66, "exp_approved": 60, "exp_denied": 6, "exp_denial_rate": 9.09, "ext_review_approved": 0, "std_tat_mean_days": 0.72, "std_tat_median_days": 0.25, "exp_tat_mean_hours": 12.9, "exp_tat_median_hours": 3.2, "reports_counts": true, "quality_flags": "error:std_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://www.tuftsmedicarepreferred.org/pa-cms-nh-exchange-report", "source_segment": "w3_newengland", "extraction_note": "Standard-request turnaround is printed on the page in HOURS, not days (verified verbatim: 'Mean (Average) Time: 17.4 hours', 'Median (Middle) Time: 5.9 hours'), unlike every other Point32Health filing in this file which prints standard TAT in days. Converted hours->days here (17.4/24=0.725, 5.9/24=0.246) to fit the std_tat_*_days field; raw printed hour values were 17.4 mean / 5.9 median. Also: printed std_approved (150) + std_denied (29) = 179, not the printed std_total of 182 — recorded exactly as printed; the 3-unit gap is unexplained by the document." }, { "filing_id": "f0013", "parent_org": "AmeriHealth Caritas", "plan_name": "AmeriHealth Caritas North Carolina", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NC", "reporting_period": "CY2025", "std_total": 77905, "std_approved": 65448, "std_denied": 11698, "std_denial_rate": 15.02, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 392, "std_appeal_overturn_rate": null, "exp_total": 1410, "exp_approved": 1192, "exp_denied": 174, "exp_denial_rate": 12.34, "ext_review_approved": null, "std_tat_mean_days": 3.46, "std_tat_median_days": 1, "exp_tat_mean_hours": 13.96, "exp_tat_median_hours": 19, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://www.amerihealthcaritasnc.com/member/rights/prior-authorization-reporting", "source_segment": "states", "extraction_note": "Reporting year not printed on the page. Expedited mean (13.96h) is LOWER than the expedited median (19h) as published." }, { "filing_id": "f0164", "parent_org": "Centene", "plan_name": "NH Healthy Families", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NH", "reporting_period": "CY2025", "std_total": 39685, "std_approved": 33320, "std_denied": 5310, "std_denial_rate": 13.38, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 730, "exp_approved": 693, "exp_denied": 37, "exp_denial_rate": 5.07, "ext_review_approved": 0, "std_tat_mean_days": 3.1, "std_tat_median_days": 0, "exp_tat_mean_hours": 45.3, "exp_tat_median_hours": 3.3, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; info:appeals_not_reported", "error_count": 1, "warn_count": 0, "source_url": "https://www.nhhealthyfamilies.com/content/dam/centene/NH%20Healthy%20Families/Medicaid/pdfs/NHHF_Prior_Authorization_Data_Metrics_Report_2025.pdf", "source_segment": "wave2", "extraction_note": "Denials labeled 'denied (including partial)'. Approved + denied (38,630) does not reconcile to the printed 39,685 total. No appeals data published." }, { "filing_id": "f0210", "parent_org": "Contra Costa Health", "plan_name": "Contra Costa Health Plan (Medi-Cal)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "CA", "reporting_period": "CY2025", "std_total": 61899, "std_approved": 51203, "std_denied": 6741, "std_denial_rate": 10.89, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 118, "std_appeal_overturn_rate": null, "exp_total": 7676, "exp_approved": 6167, "exp_denied": 885, "exp_denial_rate": 11.53, "ext_review_approved": 2087, "std_tat_mean_days": 3.75, "std_tat_median_days": 1.88, "exp_tat_mean_hours": 49.92, "exp_tat_median_hours": 17.04, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://www.cchealth.org/health-insurance/about-cchp-managed-care/apis-for-developers", "source_segment": "states", "extraction_note": "PLAN-DISCLOSED DATA QUALITY ISSUE: CCHP states a configuration issue OVERSTATED CY2025 expedited turnaround averages; fix planned for 2026. Extended-review count uses a different denominator (69,575) than the standard total." }, { "filing_id": "f0012", "parent_org": "AmeriHealth Caritas", "plan_name": "AmeriHealth Caritas Louisiana", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "LA", "reporting_period": "CY2025", "std_total": 87451, "std_approved": 76939, "std_denied": 9398, "std_denial_rate": 10.75, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 1821, "exp_approved": 1697, "exp_denied": 114, "exp_denial_rate": 6.26, "ext_review_approved": null, "std_tat_mean_days": 1.78, "std_tat_median_days": 1, "exp_tat_mean_hours": 14.14, "exp_tat_median_hours": 17, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile; info:appeals_not_reported", "error_count": 2, "warn_count": 0, "source_url": "https://www.amerihealthcaritasla.com/member/info/prior-authorization-reporting", "source_segment": "states", "extraction_note": "'Approved other than requested' published as a percentage only. Expedited mean (14.14h) is LOWER than the expedited median (17h) as published." }, { "filing_id": "f0535", "parent_org": "Wyoming Department of Health", "plan_name": "Wyoming Medicaid Utilization Management (FFS)", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "WY", "reporting_period": "CY2025", "std_total": 10708, "std_approved": 9294, "std_denied": 1106, "std_denial_rate": 10.33, "std_denial_rate_printed": null, "std_appeals_total": 20, "std_appeals_overturned": 5, "std_appeal_overturn_rate": 25, "exp_total": 0, "exp_approved": 0, "exp_denied": 0, "exp_denial_rate": null, "ext_review_approved": 0, "std_tat_mean_days": 3, "std_tat_median_days": 1, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": true, "quality_flags": "error:std_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://health.wyo.gov/wp-content/uploads/2026/03/INTEROPERABILITY_Utilization-Management.pdf", "source_segment": "wave2", "extraction_note": "Approved + denied (10,400) does not reconcile to the printed 10,708 total." }, { "filing_id": "f0316", "parent_org": "Mississippi Division of Medicaid", "plan_name": "Mississippi Medicaid Fee-for-Service", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "MS", "reporting_period": "CY2025", "std_total": 60252, "std_approved": 52480, "std_denied": 6119, "std_denial_rate": 10.16, "std_denial_rate_printed": null, "std_appeals_total": 991, "std_appeals_overturned": 720, "std_appeal_overturn_rate": 72.65, "exp_total": 39, "exp_approved": 32, "exp_denied": 6, "exp_denial_rate": 15.38, "ext_review_approved": null, "std_tat_mean_days": 3.13, "std_tat_median_days": 1, "exp_tat_mean_hours": 110.26, "exp_tat_median_hours": 27, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; warn:expedited_slower_than_standard", "error_count": 1, "warn_count": 1, "source_url": "https://medicaid.ms.gov/wp-content/uploads/2026/03/FFS-CY2025-Prior-Authorization-Metrics_MS_3.31.26.pdf", "source_segment": "states", "extraction_note": "Three-way outcome split; 'partially denied' (1,653 standard) is a separate category not folded into denied. Expedited mean TAT 110.26 hours far exceeds the 72-hour standard on a base of 39 requests." }, { "filing_id": "f0114", "parent_org": "CareOregon", "plan_name": "Columbia Pacific CCO", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "OR", "reporting_period": "CY2025", "std_total": 15531, "std_approved": 14569, "std_denied": 1230, "std_denial_rate": 7.92, "std_denial_rate_printed": 7.92, "std_appeals_total": 145, "std_appeals_overturned": 44, "std_appeal_overturn_rate": 30.34, "exp_total": 2712, "exp_approved": 2582, "exp_denied": 148, "exp_denial_rate": 5.46, "ext_review_approved": 65, "std_tat_mean_days": 3.23, "std_tat_median_days": 3, "exp_tat_mean_hours": 13, "exp_tat_median_hours": 13, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://www.colpachealth.org/members/prior-authorization-metrics-reporting", "source_segment": "w3_west", "extraction_note": "Numbers recorded exactly as printed. Standard approved (14,569) + denied (1,230) = 15,799 vs printed std_total 15,531 (gap of 268) — flagged, not corrected. Expedited approved (2,582) + denied (148) = 2,730 vs printed exp_total 2,712 (gap of 18) — also flagged. Page prints an additional expedited extended-review figure as '20 out of 31 instances (64.51%)', which has no matching schema field and is recorded here only." }, { "filing_id": "f0115", "parent_org": "CareOregon", "plan_name": "Jackson Care Connect", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "OR", "reporting_period": "CY2025", "std_total": 34544, "std_approved": 32263, "std_denied": 2631, "std_denial_rate": 7.62, "std_denial_rate_printed": 7.61, "std_appeals_total": 323, "std_appeals_overturned": 99, "std_appeal_overturn_rate": 30.65, "exp_total": 3749, "exp_approved": 3623, "exp_denied": 157, "exp_denial_rate": 4.19, "ext_review_approved": 155, "std_tat_mean_days": 3.85, "std_tat_median_days": 1, "exp_tat_mean_hours": 18, "exp_tat_median_hours": 18, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://www.jacksoncareconnect.org/members/prior-authorization-metrics-reporting", "source_segment": "w3_west", "extraction_note": "Numbers recorded exactly as printed. Standard approved (32,263) + denied (2,631) = 34,894, which does not match the printed std_total of 34,544 (a gap of 350) — flagged, not corrected. Expedited approved (3,623) + denied (157) = 3,780 vs printed exp_total of 3,749 (gap of 31) — also flagged. Page additionally prints 'expedited approved after extended review time: 26 (0.70%)' for which there is no schema field (only std has an ext_review_approved slot); recorded here only." }, { "filing_id": "cfhp-starplus", "parent_org": "Community First Health Plans", "plan_name": "Community First Texas Medicaid STAR+PLUS", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "TX", "reporting_period": "CY2025", "std_total": 8980, "std_approved": 7715, "std_denied": 646, "std_denial_rate": 7.19, "std_denial_rate_printed": null, "std_appeals_total": 88, "std_appeals_overturned": 31, "std_appeal_overturn_rate": 35.23, "exp_total": 5421, "exp_approved": 4242, "exp_denied": 233, "exp_denial_rate": 4.3, "ext_review_approved": null, "std_tat_mean_days": 5, "std_tat_median_days": 4, "exp_tat_mean_hours": 36, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://medicaid.communityfirsthealthplans.com/wp-content/uploads/sites/2/2026/03/2025-Prior-Authorization-Metrics-for-Medical-Items-Services-Excluding-Drugs.pdf", "source_segment": "filings_2025", "extraction_note": null }, { "filing_id": "f0315", "parent_org": "Michigan Department of Health and Human Services", "plan_name": "Michigan Medicaid Home and Community Based Services (Aging and Community Services Division, incl. Brain Injury Services and Community Transition Services) - Fee-for-Service", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "MI", "reporting_period": "CY2025", "std_total": 3371, "std_approved": 3165, "std_denied": 175, "std_denial_rate": 5.19, "std_denial_rate_printed": 5.19, "std_appeals_total": 0, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": null, "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": "error:std_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Medicaid-Provider-Assets/CHAMPS/HCBS-2025-Prior-Authorization-Annual-Report.pdf?rev=870074c81a0c4cb09e5f61c77b72c9c8&hash=7F9B18D0B199E145BE70AFF7F2D04825", "source_segment": "w3_midwest", "extraction_note": "Document reports one combined total (3,371 requests; 3,165 approved/93.89%; 175 denied/5.19%) and does NOT split standard vs. expedited. The document itself states that standard/expedited breakout 'is a requirement of CMS-0057-F' but 'Fee-for-Service Michigan Medicaid implementation of collection of this data is effective 4/1/2026' -- so CY2025 requests are combined. Recorded the combined counts under std_total/std_approved/std_denied for lack of a better bucket; treat as combined, not standard-only. Turnaround time was 'not actively tracked in 2025' -- left null, not estimated. Appeals row printed 'Number of PA Requests with a Decision Outcome following Appeal: 0' -- recorded as std_appeals_total=0 (a real printed zero, not an absence) but it is unclear whether this denominator counts appeals filed or appeals decided; treat cautiously. Approved (3,165) + denied (175) = 3,340, not 3,371 -- recorded as printed; the shortfall is presumably pending/withdrawn requests not broken out." }, { "filing_id": "cfhp-starkids", "parent_org": "Community First Health Plans", "plan_name": "Community First Texas Medicaid STAR Kids", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "TX", "reporting_period": "CY2025", "std_total": 12378, "std_approved": 10773, "std_denied": 638, "std_denial_rate": 5.15, "std_denial_rate_printed": null, "std_appeals_total": 235, "std_appeals_overturned": 86, "std_appeal_overturn_rate": 36.6, "exp_total": 1773, "exp_approved": 1713, "exp_denied": 58, "exp_denial_rate": 3.27, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 4, "exp_tat_mean_hours": 40.6, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "error:std_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://medicaid.communityfirsthealthplans.com/wp-content/uploads/sites/2/2026/03/2025-Prior-Authorization-Metrics-for-Medical-Items-Services-Excluding-Drugs.pdf", "source_segment": "filings_2025", "extraction_note": null }, { "filing_id": "f0241", "parent_org": "Geisinger Health", "plan_name": "Geisinger Health Plan (all lines of business, aggregated)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "PA", "reporting_period": "CY2025", "std_total": 311379, "std_approved": 295329, "std_denied": 15932, "std_denial_rate": 5.12, "std_denial_rate_printed": null, "std_appeals_total": 1963, "std_appeals_overturned": 909, "std_appeal_overturn_rate": 46.31, "exp_total": 3039, "exp_approved": 2830, "exp_denied": 168, "exp_denial_rate": 5.53, "ext_review_approved": 1627, "std_tat_mean_days": 0.84, "std_tat_median_days": 0.01, "exp_tat_mean_hours": 0.69, "exp_tat_median_hours": 0.04, "reports_counts": true, "quality_flags": "error:exp_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://www.geisinger.org/health-plan/members/prior-authorization-report", "source_segment": "regional", "extraction_note": "MAJOR CAVEAT: one aggregated table covering MA, Medicaid and QHP with no per-line breakout; coverage_type is a placeholder and these figures are NOT MA-specific. TAT columns carry no unit labels; expedited unit is an assumption." }, { "filing_id": "f0393", "parent_org": "Sentara Health", "plan_name": "Sentara Health Plans - Medicare", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "VA", "reporting_period": "CY2025", "std_total": 49506, "std_approved": 46995, "std_denied": 2511, "std_denial_rate": 5.07, "std_denial_rate_printed": null, "std_appeals_total": 127, "std_appeals_overturned": 134, "std_appeal_overturn_rate": 105.51, "exp_total": 5527, "exp_approved": 5371, "exp_denied": 156, "exp_denial_rate": 2.82, "ext_review_approved": 0, "std_tat_mean_days": 4.8, "std_tat_median_days": 2, "exp_tat_mean_hours": 22, "exp_tat_median_hours": 4, "reports_counts": true, "quality_flags": "error:appeals_exceed_total", "error_count": 1, "warn_count": 0, "source_url": "https://www.sentarahealthplans.com/en/company/policies/prior-authorization-metrics", "source_segment": "regional", "extraction_note": "CONTRADICTION: 134 overturns against a stated denominator of 127 appeals, printed at 0%. The denominator 127 is identical to the Commercial section's, suggesting a copy error." }, { "filing_id": "cfhp-star", "parent_org": "Community First Health Plans", "plan_name": "Community First Texas Medicaid STAR", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "TX", "reporting_period": "CY2025", "std_total": 20481, "std_approved": 18828, "std_denied": 955, "std_denial_rate": 4.66, "std_denial_rate_printed": null, "std_appeals_total": 192, "std_appeals_overturned": 89, "std_appeal_overturn_rate": 46.35, "exp_total": 8994, "exp_approved": 7178, "exp_denied": 276, "exp_denial_rate": 3.07, "ext_review_approved": null, "std_tat_mean_days": 6, "std_tat_median_days": 4, "exp_tat_mean_hours": 33.6, "exp_tat_median_hours": 48, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://medicaid.communityfirsthealthplans.com/wp-content/uploads/sites/2/2026/03/2025-Prior-Authorization-Metrics-for-Medical-Items-Services-Excluding-Drugs.pdf", "source_segment": "filings_2025", "extraction_note": null }, { "filing_id": "cfhp-chip", "parent_org": "Community First Health Plans", "plan_name": "Community First CHIP", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "TX", "reporting_period": "CY2025", "std_total": 1268, "std_approved": 1208, "std_denied": 58, "std_denial_rate": 4.57, "std_denial_rate_printed": null, "std_appeals_total": 10, "std_appeals_overturned": 3, "std_appeal_overturn_rate": 30, "exp_total": 242, "exp_approved": 174, "exp_denied": 24, "exp_denial_rate": 9.92, "ext_review_approved": null, "std_tat_mean_days": 3, "std_tat_median_days": 2, "exp_tat_mean_hours": 40.6, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "error:exp_counts_reconcile", "error_count": 1, "warn_count": 0, "source_url": "https://medicaid.communityfirsthealthplans.com/wp-content/uploads/sites/2/2026/03/2025-Prior-Authorization-Metrics-for-Medical-Items-Services-Excluding-Drugs.pdf", "source_segment": "filings_2025", "extraction_note": null }, { "filing_id": "f0533", "parent_org": "Wisconsin Department of Health Services", "plan_name": "Wisconsin Medicaid (ForwardHealth) -- specific program/agency not named in document", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "WI", "reporting_period": "Reporting Year 2025", "std_total": 165012, "std_approved": 148796, "std_denied": 6556, "std_denial_rate": 3.97, "std_denial_rate_printed": 4, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 10, "exp_approved": 9, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 3.1, "std_tat_median_days": 1, "exp_tat_mean_hours": 151.2, "exp_tat_median_hours": 67.2, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; info:appeals_not_reported; warn:expedited_slower_than_standard", "error_count": 1, "warn_count": 1, "source_url": "https://www.dhs.wisconsin.gov/medicaid/pa-report-2025.pdf", "source_segment": "w3_midwest", "extraction_note": "Document title is only 'Prior Authorization Metrics Reporting Year 2025' -- it names no specific plan, MCO, or program (no BadgerCare Plus / ForwardHealth / managed-care label appears). Hosted on the WI DHS Medicaid pages alongside ForwardHealth FFS pharmacy/PA administrative-code material, so classified here as Medicaid FFS, but this could instead be a statewide combined FFS+MCO carve-in PA determination log -- flag for verification by someone who can see the full PDF. Document also reports a separate 'Partially Denied' bucket not in this schema: standard 9,660 (5.9%%), expedited 1 -- omitted from typed fields, noted here. Standard TAT is explicitly labeled in days (3.1 mean / 1.0 median). Expedited TAT is ALSO explicitly labeled in days (6.3 mean / 2.8 median) rather than hours; converted per brief instructions (days->hours: 6.3*24=151.2, 2.8*24=67.2) and flagged as a conversion. Note the apparent anomaly that expedited turnaround (151.2h / 67.2h) is far slower than standard (3.1 days = 74.4h / 1.0 day = 24h) -- printed as-is; worth scrutiny downstream. No appeals data reported." }, { "filing_id": "cfhp-marketplace", "parent_org": "Community First Health Plans", "plan_name": "University Community Care Plan (Marketplace)", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "TX", "reporting_period": "CY2025", "std_total": 2726, "std_approved": 2631, "std_denied": 76, "std_denial_rate": 2.79, "std_denial_rate_printed": null, "std_appeals_total": 9, "std_appeals_overturned": 6, "std_appeal_overturn_rate": 66.67, "exp_total": 499, "exp_approved": 358, "exp_denied": 28, "exp_denial_rate": 5.61, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 2, "exp_tat_mean_hours": 40.1, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://exchange.communityfirsthealthplans.com/wp-content/uploads/sites/4/2026/03/2025-Prior-Authorization-Metrics-for-Medical-Items-Services-Excluding-Drugs.pdf", "source_segment": "filings_2025", "extraction_note": null }, { "filing_id": "cfhp-ma", "parent_org": "Community First Health Plans", "plan_name": "Community First Medicare Advantage (Alamo & D-SNP)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "TX", "reporting_period": "CY2025", "std_total": 508, "std_approved": 482, "std_denied": 13, "std_denial_rate": 2.56, "std_denial_rate_printed": null, "std_appeals_total": 6, "std_appeals_overturned": 1, "std_appeal_overturn_rate": 16.67, "exp_total": 142, "exp_approved": 110, "exp_denied": 7, "exp_denial_rate": 4.93, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 3, "exp_tat_mean_hours": 54.7, "exp_tat_median_hours": 48, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://exchange.communityfirsthealthplans.com/wp-content/uploads/sites/4/2026/03/2025-Prior-Authorization-Metrics-for-Medical-Items-Services-Excluding-Drugs.pdf", "source_segment": "filings_2025", "extraction_note": "Source prints expedited denied as 67% where 7/142 = 4.9%." } ] }