{ "meta": { "total": 13, "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": "f0132", "parent_org": "Centene", "plan_name": "Ambetter from Arizona Complete Health (91450)", "contract_id": "91450", "coverage_type": "Marketplace QHP", "state": "AZ", "reporting_period": "CY2025", "std_total": 54027, "std_approved": 39983, "std_denied": 14044, "std_denial_rate": 25.99, "std_denial_rate_printed": null, "std_appeals_total": 378, "std_appeals_overturned": 141, "std_appeal_overturn_rate": 37.3, "exp_total": 3730, "exp_approved": 2834, "exp_denied": 896, "exp_denial_rate": 24.02, "ext_review_approved": 1039, "std_tat_mean_days": 4, "std_tat_median_days": 1, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.ambetterhealth.com/content/dam/centene/ambetteraz/pdfs/AZ_MKT_AZCompleteHealth_91450_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "contract_id is the HIOS issuer ID.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:AZ:91450", "filing_unit": "qhp_issuer" }, { "filing_id": "f0146", "parent_org": "Centene", "plan_name": "Arizona Complete Health - Complete Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "AZ", "reporting_period": "CY2025", "std_total": 164338, "std_approved": 126036, "std_denied": 38302, "std_denial_rate": 23.31, "std_denial_rate_printed": null, "std_appeals_total": 1493, "std_appeals_overturned": 453, "std_appeal_overturn_rate": 30.34, "exp_total": 17287, "exp_approved": 15169, "exp_denied": 2118, "exp_denial_rate": 12.25, "ext_review_approved": 124, "std_tat_mean_days": 5, "std_tat_median_days": 2, "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://www.azcompletehealth.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/AZ-AzCH_Medicaid_102_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "Centene template; expedited TAT converted days->hours.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:AZ:arizona-complete-health-complete-care-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0493", "parent_org": "UnitedHealth Group", "plan_name": "Arizona AHCCCS Complete Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "AZ", "reporting_period": "CY2025", "std_total": 94879, "std_approved": 73857, "std_denied": 21022, "std_denial_rate": 22.16, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 216, "std_appeal_overturn_rate": null, "exp_total": 11550, "exp_approved": 10307, "exp_denied": 1243, "exp_denial_rate": 10.76, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 2.4, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 19.2, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicaid-2025.pdf", "source_segment": "wave2", "extraction_note": "Totals computed as approved+not approved; expedited TAT converted days->hours.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:AZ:arizona-complete-health-complete-care-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0426", "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.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:AZ:13877", "filing_unit": "qhp_issuer" }, { "filing_id": "f0181", "parent_org": "Centene", "plan_name": "Wellcare Medicare Advantage H0351", "contract_id": "H0351", "coverage_type": "Medicare Advantage", "state": "AZ", "reporting_period": "CY2025", "std_total": 33259, "std_approved": 27519, "std_denied": 5740, "std_denial_rate": 17.26, "std_denial_rate_printed": null, "std_appeals_total": 690, "std_appeals_overturned": 660, "std_appeal_overturn_rate": 95.65, "exp_total": 2439, "exp_approved": 2094, "exp_denied": 345, "exp_denial_rate": 14.15, "ext_review_approved": 0, "std_tat_mean_days": 3, "std_tat_median_days": 1, "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://www.azcompletehealth.com/content/dam/centene/medicare/pdfs/national/provider/prior-authorization-requirements-metrics/AZ_Wellcare_Medicare_H0351_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "95.7% appeal overturn rate. Published on the Arizona provider site though the contract may span more than Arizona.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H0351", "filing_unit": "ma_contract" }, { "filing_id": "f0183", "parent_org": "Centene", "plan_name": "Wellcare Medicare Advantage H5590", "contract_id": "H5590", "coverage_type": "Medicare Advantage", "state": "AZ", "reporting_period": "CY2025", "std_total": 43816, "std_approved": 36335, "std_denied": 7481, "std_denial_rate": 17.07, "std_denial_rate_printed": null, "std_appeals_total": 826, "std_appeals_overturned": 780, "std_appeal_overturn_rate": 94.43, "exp_total": 2871, "exp_approved": 2479, "exp_denied": 392, "exp_denial_rate": 13.65, "ext_review_approved": 0, "std_tat_mean_days": 3, "std_tat_median_days": 2, "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://www.azcompletehealth.com/content/dam/centene/medicare/pdfs/national/provider/prior-authorization-requirements-metrics/AZ_Wellcare_Medicare_H5590_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "94.4% appeal overturn rate.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5590", "filing_unit": "ma_contract" }, { "filing_id": "f0030", "parent_org": "Blue Cross Blue Shield of Arizona", "plan_name": "Individual Affordable Care Act Plan Members", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "AZ", "reporting_period": "2025", "std_total": 34329, "std_approved": 29927, "std_denied": 4402, "std_denial_rate": 12.82, "std_denial_rate_printed": 12.82, "std_appeals_total": 363, "std_appeals_overturned": 164, "std_appeal_overturn_rate": 45.18, "exp_total": 3124, "exp_approved": 2832, "exp_denied": 292, "exp_denial_rate": 9.35, "ext_review_approved": null, "std_tat_mean_days": 3.45, "std_tat_median_days": 0.32, "exp_tat_mean_hours": 20.36, "exp_tat_median_hours": 2.9, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.azblue.com/m/3a748505efc6198f/original/2025-ACA-Prior-Auth-Metrics-Report.pdf", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "a55f51d9fef968c913b0cf182615a48d9e0015f4c1a30195e95d3cf58002d6fb", "service_list_url": null, "service_list_items": null, "entity_id": "qhp:AZ:53901", "filing_unit": "qhp_issuer" }, { "filing_id": "f0028", "parent_org": "Blue Cross Blue Shield of Arizona", "plan_name": "AZ Blue Health Choice (AHCCCS)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "AZ", "reporting_period": "CY2025", "std_total": 71937, "std_approved": 63222, "std_denied": 8715, "std_denial_rate": 12.11, "std_denial_rate_printed": null, "std_appeals_total": 296, "std_appeals_overturned": 111, "std_appeal_overturn_rate": 37.5, "exp_total": 10209, "exp_approved": 9416, "exp_denied": 793, "exp_denial_rate": 7.77, "ext_review_approved": 49, "std_tat_mean_days": 3.96, "std_tat_median_days": 1.09, "exp_tat_mean_hours": 16.1, "exp_tat_median_hours": 2.78, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.azblue.com/m/111e9ce8c59e052a/original/2025-Medicaid-Metrics-Report.pdf", "source_segment": "wave2", "extraction_note": null, "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:AZ:health-choice-arizona", "filing_unit": "medicaid_plan" }, { "filing_id": "f0494", "parent_org": "UnitedHealth Group", "plan_name": "Arizona Developmental Disabilities Program", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "AZ", "reporting_period": "CY2025", "std_total": 10440, "std_approved": 9424, "std_denied": 1016, "std_denial_rate": 9.73, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 89, "std_appeal_overturn_rate": null, "exp_total": 615, "exp_approved": 572, "exp_denied": 43, "exp_denial_rate": 6.99, "ext_review_approved": null, "std_tat_mean_days": 5, "std_tat_median_days": 5.2, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 14.4, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicaid-2025.pdf", "source_segment": "wave2", "extraction_note": "Expedited TAT converted days->hours. Appeal overturn printed 100% with no denominator.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:AZ:health-choice-arizona", "filing_unit": "medicaid_plan" }, { "filing_id": "f0390", "parent_org": "Molina Healthcare", "plan_name": "Molina Complete Care of Arizona (AHCCCS Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "AZ", "reporting_period": "2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 9, "std_denial_rate_printed": 9, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 53, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 11, "ext_review_approved": null, "std_tat_mean_days": 6, "std_tat_median_days": 5, "exp_tat_mean_hours": 27, "exp_tat_median_hours": 21, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.molinahealthcare.com/providers/az/medicaid/forms/fuf.aspx", "source_segment": "w3_west", "extraction_note": "Document titled 'MCCAZ Medicaid Prior Authorization Report 2025'; all values are whole-number percentages, no raw counts published (reports_counts=false). Document also prints 'extended timeframe approvals: 63%' (standard) and, for expedited, 'approved after appeal: 71%' and 'extended timeframe approvals: 61%' — none of which have matching schema fields (schema has no expedited-appeal or percentage-only ext-review slots) and are recorded here only. The standard and expedited appeal-overturn percentages (53% and 71%) are unusually high relative to other filings in this dataset and worth a second look; denominator (of denials, or of all appeals filed) is not stated in the document.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:AZ:arizona-complete-health-complete-care-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0029", "parent_org": "Blue Cross Blue Shield of Arizona", "plan_name": "AZ Blue Health Choice Pathway (D-SNP)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "AZ", "reporting_period": "CY2025", "std_total": 11931, "std_approved": 10928, "std_denied": 1003, "std_denial_rate": 8.41, "std_denial_rate_printed": null, "std_appeals_total": 138, "std_appeals_overturned": 71, "std_appeal_overturn_rate": 51.45, "exp_total": 1218, "exp_approved": 1136, "exp_denied": 82, "exp_denial_rate": 6.73, "ext_review_approved": 6, "std_tat_mean_days": 3.78, "std_tat_median_days": 1.98, "exp_tat_mean_hours": 19.93, "exp_tat_median_hours": 2.82, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.azblue.com/m/7d1ddd4e92f179c2/original/2025-DSNP-Metrics-Report.pdf", "source_segment": "wave2", "extraction_note": null, "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5587", "filing_unit": "ma_contract" }, { "filing_id": "f0031", "parent_org": "Blue Cross Blue Shield of Arizona", "plan_name": "Medicare Advantage", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "AZ", "reporting_period": "2025", "std_total": 37315, "std_approved": 35217, "std_denied": 2098, "std_denial_rate": 5.62, "std_denial_rate_printed": 5.62, "std_appeals_total": 477, "std_appeals_overturned": 434, "std_appeal_overturn_rate": 90.99, "exp_total": 4443, "exp_approved": 4174, "exp_denied": 269, "exp_denial_rate": 6.05, "ext_review_approved": null, "std_tat_mean_days": 2.11, "std_tat_median_days": 1, "exp_tat_mean_hours": 11.83, "exp_tat_median_hours": 2.52, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.azblue.com/m/4f85025f7b61a595/original/2025-MA-Prior-Auth-Metrics-Report.pdf", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "35a48f477a0595e86c666e26e91b37f9fcf6832ce986b88d8dbee01318681a64", "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5587", "filing_unit": "ma_contract" }, { "filing_id": "f0495", "parent_org": "UnitedHealth Group", "plan_name": "Arizona Long Term Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "AZ", "reporting_period": "CY2025", "std_total": 45798, "std_approved": 43674, "std_denied": 2124, "std_denial_rate": 4.64, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 37, "std_appeal_overturn_rate": null, "exp_total": 612, "exp_approved": 438, "exp_denied": 174, "exp_denial_rate": 28.43, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 29.7, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 21.6, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicaid-2025.pdf", "source_segment": "wave2", "extraction_note": "Standard mean (1 day) far below median (29.7 days) as printed.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:AZ:health-choice-arizona", "filing_unit": "medicaid_plan" } ] }