{ "meta": { "total": 7, "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": "f0164", "parent_org": "Centene", "plan_name": "Meridian Illinois Medicaid", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IL", "reporting_period": "CY2025", "std_total": 316252, "std_approved": 244732, "std_denied": 71520, "std_denial_rate": 22.61, "std_denial_rate_printed": null, "std_appeals_total": 4735, "std_appeals_overturned": 2297, "std_appeal_overturn_rate": 48.51, "exp_total": 7605, "exp_approved": 6581, "exp_denied": 1024, "exp_denial_rate": 13.46, "ext_review_approved": 4236, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.ilmeridian.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/IL_Meridian_Medicaid_204_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "Illinois non-urgent turnaround standard changed 7/1/2025 from 5 business days to 48 hours, so the annual average mixes two standards.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IL:meridian-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0063", "parent_org": "CVS Health / Aetna", "plan_name": "Aetna Better Health of Illinois", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IL", "reporting_period": "CY2025", "std_total": 110555, "std_approved": 93277, "std_denied": 17278, "std_denial_rate": 15.63, "std_denial_rate_printed": null, "std_appeals_total": 3284, "std_appeals_overturned": 432, "std_appeal_overturn_rate": 13.15, "exp_total": 5187, "exp_approved": 4258, "exp_denied": 929, "exp_denial_rate": 17.91, "ext_review_approved": 1562, "std_tat_mean_days": 1.28, "std_tat_median_days": 1, "exp_tat_mean_hours": 20.88, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/illinois/providers/pdf/2025_ABHIL_CMS_Web_Metrics-Provider.pdf", "source_segment": "wave2", "extraction_note": "Expedited TAT converted days->hours; median exceeds mean as printed.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IL:aetna-better-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0394", "parent_org": "Molina Healthcare", "plan_name": "Molina Healthcare of Illinois (Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IL", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 14, "std_denial_rate_printed": 14, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 52, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 8, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 20, "exp_tat_median_hours": 19, "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/il/medicaid/forms/fuf.aspx", "source_segment": "w3_gaps_a", "extraction_note": "Table appears under the heading 'Illinois Medicaid Prior Authorization Annual Report 2025' (same fuf.aspx architecture as the California and Florida sibling filings). Percentages only. Figures with no corresponding schema field: expedited-request appeal overturn 69%; extended-timeframe requests approved 64% (standard) / 74% (expedited). Same verification caveat applies.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IL:molina-healthcare", "filing_unit": "medicaid_plan" }, { "filing_id": "f0186", "parent_org": "Centene", "plan_name": "YouthCare (HealthChoice Illinois Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IL", "reporting_period": "CY2025 (effective 12/31/2025)", "std_total": 10423, "std_approved": 9052, "std_denied": 1371, "std_denial_rate": 13.15, "std_denial_rate_printed": 13.15, "std_appeals_total": null, "std_appeals_overturned": 111, "std_appeal_overturn_rate": null, "exp_total": 261, "exp_approved": 230, "exp_denied": 31, "exp_denial_rate": 11.88, "ext_review_approved": 581, "std_tat_mean_days": 1, "std_tat_median_days": 0, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.ilyouthcare.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/IL_Meridian_Medicaid_Youth_MetricsSummary_R.pdf", "source_segment": "w3_midwest", "extraction_note": "Document also reports 'Approved After Time Extension' and 'Approved After Appeal' broken out separately for expedited requests (9 and 1 respectively) -- schema only has one ext_review_approved and one std_appeals_overturned field, so only the standard-line figures (581 and 111) are typed; expedited figures noted here only. No appeals-filed denominator was printed for either standard or expedited 'Approved After Appeal' counts, so std_appeals_total is omitted (not zero -- simply not published). Expedited average/median turnaround is printed as '0 days' for both -- given only 261 expedited requests this is plausibly a rounded-down small value rather than a true zero; recorded as printed (0 hours after unit conversion) but flagged as possibly a rounding artifact. Document carries the standard CMS-0057-F disclaimer that figures may differ from other regulatory submissions.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IL:youthcare", "filing_unit": "medicaid_plan" }, { "filing_id": "f0207", "parent_org": "CountyCare Health Plan (Cook County Health)", "plan_name": "CountyCare Health Plan (HealthChoice Illinois Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IL", "reporting_period": "CY2025", "std_total": 241756, "std_approved": 217490, "std_denied": 24266, "std_denial_rate": 10.04, "std_denial_rate_printed": 10, "std_appeals_total": 889, "std_appeals_overturned": 213, "std_appeal_overturn_rate": 23.96, "exp_total": 35841, "exp_approved": 34596, "exp_denied": 1245, "exp_denial_rate": 3.47, "ext_review_approved": null, "std_tat_mean_days": 0.87, "std_tat_median_days": 0.26, "exp_tat_mean_hours": 21.12, "exp_tat_median_hours": 18.48, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://countycare.com/wp-content/uploads/2025-CCHP-CMS-0057-F-Prior-Auth-Metrics-Updated-003_brandupdate_03.27.2026.pdf", "source_segment": "w3_midwest", "extraction_note": "Expedited appeals were also reported separately from standard (176 total appeals, 127 overturned, 72.2% overturn rate) but this schema has no exp_appeals fields, so only the standard-appeal figures (889/213/24.0%) are in typed fields -- expedited appeal counts noted here only. Document labels expedited TAT in days (0.88 mean / 0.77 median); converted to hours per brief instructions (0.88*24=21.12, 0.77*24=18.48) and flagged as a conversion.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IL:countycare-health-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "abh-premier-h2506", "parent_org": "CVS Health / Aetna", "plan_name": "Aetna Better Health Premier Plan (Medicare-Medicaid)", "contract_id": "H2506", "coverage_type": "Medicare-Medicaid Plan", "state": "IL", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 6.55, "std_denial_rate_printed": 6.55, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 23.17, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 5.74, "ext_review_approved": null, "std_tat_mean_days": 4.51, "std_tat_median_days": 2, "exp_tat_mean_hours": 27.12, "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://www.aetnabetterhealth.com/content/dam/aetna/medicaid/illinois/pdf/abhil_PA_metric_reporting_template_MA_v3_Approved_H2506.pdf", "source_segment": "filings_2025", "extraction_note": null, "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IL:aetna-better-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0313", "parent_org": "Humana", "plan_name": "Humana Healthy Horizons in Illinois", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IL", "reporting_period": "2025", "std_total": 15116, "std_approved": 14552, "std_denied": 564, "std_denial_rate": 3.73, "std_denial_rate_printed": 3.73, "std_appeals_total": 6, "std_appeals_overturned": 4, "std_appeal_overturn_rate": 66.67, "exp_total": 243, "exp_approved": 232, "exp_denied": 11, "exp_denial_rate": 4.53, "ext_review_approved": 0, "std_tat_mean_days": 0, "std_tat_median_days": 0, "exp_tat_mean_hours": 5, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://assets.humana.com/is/content/humana/Humana_IL_Prior_Auth_Metrics_PlanYear2025pdf", "source_segment": "w5_humana", "extraction_note": "parsed from the published template by pipeline.preauth.extract (humana)", "source_sha256": "811d1d131d9d3d6683cfe947d9c22fba8b479cfa4b5a1f056d9e05c49ccde63c", "service_list_url": "https://provider.humana.com/MedicaidPAL", "service_list_items": null, "entity_id": null, "filing_unit": null } ] }