{ "meta": { "total": 8, "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": "f0020", "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.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0019", "parent_org": "AmeriHealth Caritas Family of Companies", "plan_name": "AmeriHealth Caritas Delaware (Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "DE", "reporting_period": "CY2025", "std_total": 70575, "std_approved": 50588, "std_denied": 19987, "std_denial_rate": 28.32, "std_denial_rate_printed": 28.3, "std_appeals_total": null, "std_appeals_overturned": 305, "std_appeal_overturn_rate": null, "exp_total": 6971, "exp_approved": 6110, "exp_denied": 861, "exp_denial_rate": 12.35, "ext_review_approved": null, "std_tat_mean_days": 3.4, "std_tat_median_days": 3, "exp_tat_mean_hours": 35.6, "exp_tat_median_hours": 22, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.amerihealthcaritasde.com/rights/prior-authorization-reporting", "source_segment": "aetna_ahc", "extraction_note": "std_appeals_overturned is the printed 'approved after appeal' count (305 standard; 971 denied after appeal). Expedited approved after appeal: 82; denied after appeal: 10. Total appeals filed not printed separately.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:DE:amerihealth-caritas-of-delaware", "filing_unit": "medicaid_plan" }, { "filing_id": "f0130", "parent_org": "Centene", "plan_name": "Ambetter Health of Delaware", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "DE", "reporting_period": "CY2025", "std_total": 2946, "std_approved": 2131, "std_denied": 815, "std_denial_rate": 27.66, "std_denial_rate_printed": 27.66, "std_appeals_total": 35, "std_appeals_overturned": 11, "std_appeal_overturn_rate": 31.43, "exp_total": 168, "exp_approved": 132, "exp_denied": 36, "exp_denial_rate": 21.43, "ext_review_approved": null, "std_tat_mean_days": 5, "std_tat_median_days": 4, "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.ambetterhealth.com/content/dam/centene/ambetter-delaware/pdf/DE_MKT_AHofDE_64004_MetricsSummary_R.pdf", "source_segment": "w3_qhp", "extraction_note": "Issuer ID 64004. Expedited appeals: 6 total, 2 overturned (33.33%). Expedited TAT printed in days (mean 1, median 1); converted to hours (24h/24h) - native unit was days.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:DE:64004", "filing_unit": "qhp_issuer" }, { "filing_id": "f0155", "parent_org": "Centene", "plan_name": "Delaware First Health Medicaid", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "DE", "reporting_period": "CY2025", "std_total": 15081, "std_approved": 13155, "std_denied": 1926, "std_denial_rate": 12.77, "std_denial_rate_printed": null, "std_appeals_total": 53, "std_appeals_overturned": 33, "std_appeal_overturn_rate": 62.26, "exp_total": 367, "exp_approved": 320, "exp_denied": 47, "exp_denial_rate": 12.81, "ext_review_approved": 641, "std_tat_mean_days": 4, "std_tat_median_days": 2, "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.delawarefirsthealth.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/DE_CAID_Medicaid_DE_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:DE:delaware-first-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0277", "parent_org": "Highmark", "plan_name": "Highmark Medicare Advantage contract H7710", "contract_id": "H7710", "coverage_type": "Medicare Advantage", "state": "DE", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": 671, "std_approved": 588, "std_denied": 83, "std_denial_rate": 12.37, "std_denial_rate_printed": 12, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 41, "exp_approved": 37, "exp_denied": 4, "exp_denial_rate": 9.76, "ext_review_approved": 5, "std_tat_mean_days": 4.8, "std_tat_median_days": 5, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": true, "quality_flags": "info:appeals_not_reported", "error_count": 0, "warn_count": 0, "source_url": "https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf", "source_segment": "blues", "extraction_note": "Consolidated Highmark CMS-0057-F filing hosted on the Highmark Health Options DE provider site; it covers MA, Medicaid and QHP business across PA/DE/WV/NY. Plan marketing name and state are not printed next to most contract IDs. Extended-review values recorded here are the STANDARD-request extension rows. Decision times are printed as '<1 day' for both standard and expedited unless noted, so numeric TAT is left null. DE D-SNP. No appeals data reported for this contract. Expedited extended review: 1 total / 0 approved / 1 denied.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H7710", "filing_unit": "ma_contract" }, { "filing_id": "f0154", "parent_org": "Centene", "plan_name": "Delaware First Health CHIP", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "DE", "reporting_period": "CY2025", "std_total": 618, "std_approved": 543, "std_denied": 75, "std_denial_rate": 12.14, "std_denial_rate_printed": null, "std_appeals_total": 3, "std_appeals_overturned": 3, "std_appeal_overturn_rate": 100, "exp_total": 9, "exp_approved": 8, "exp_denied": 1, "exp_denial_rate": 11.11, "ext_review_approved": 25, "std_tat_mean_days": 2, "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.delawarefirsthealth.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/DE_CAID_Medicaid_CHIP_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "Very small denominators.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0279", "parent_org": "Highmark", "plan_name": "Highmark QHP (federal Marketplace) - Delaware", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "DE", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": 16283, "std_approved": 14939, "std_denied": 1344, "std_denial_rate": 8.25, "std_denial_rate_printed": 8, "std_appeals_total": 5, "std_appeals_overturned": 3, "std_appeal_overturn_rate": 60, "exp_total": 3343, "exp_approved": 3056, "exp_denied": 287, "exp_denial_rate": 8.59, "ext_review_approved": null, "std_tat_mean_days": 0.68, "std_tat_median_days": 0, "exp_tat_mean_hours": 12.24, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf", "source_segment": "blues", "extraction_note": "Expedited decision time was published in DAYS and converted to hours (x24); standard TAT left in days as published. No standard extended-review figures printed for the QHP rows. Expedited extended review 1 total / 1 approved. Expedited appeals: 7 total, 3 approved.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:DE:76168", "filing_unit": "qhp_issuer" }, { "filing_id": "f0267", "parent_org": "Highmark", "plan_name": "Highmark Medicaid - Delaware", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "DE", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": 32291, "std_approved": 31809, "std_denied": 482, "std_denial_rate": 1.49, "std_denial_rate_printed": 1, "std_appeals_total": 156, "std_appeals_overturned": 38, "std_appeal_overturn_rate": 24.36, "exp_total": 1098, "exp_approved": 1060, "exp_denied": 38, "exp_denial_rate": 3.46, "ext_review_approved": 838, "std_tat_mean_days": 3.8, "std_tat_median_days": 4, "exp_tat_mean_hours": 40.8, "exp_tat_median_hours": 36, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf", "source_segment": "blues", "extraction_note": "Section heading in the extracted text reads 'State Medicaid & CHIP FFS programs'; Highmark operates as a managed care organization, so coded Medicaid Managed Care - the heading is ambiguous and may mean these rows mix FFS and MCO business. Expedited TAT converted from days to hours (mean 1.7 d x 24 = 40.8 h; median 1.5 d x 24 = 36 h).", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:DE:highmark-health-options-of-delaware", "filing_unit": "medicaid_plan" } ] }