{ "meta": { "total": 11, "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": "f0162", "parent_org": "Centene", "plan_name": "MHS Indiana - Hoosier Care Connect", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": "CY2025", "std_total": 28213, "std_approved": 21110, "std_denied": 7103, "std_denial_rate": 25.18, "std_denial_rate_printed": null, "std_appeals_total": 1062, "std_appeals_overturned": 351, "std_appeal_overturn_rate": 33.05, "exp_total": 700, "exp_approved": 571, "exp_denied": 129, "exp_denial_rate": 18.43, "ext_review_approved": 4031, "std_tat_mean_days": 3, "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.mhsindiana.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/IN_HoosierHC_Medicaid_HCC_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "Plan discloses some PA requests may not be fully captured due to system limitations.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:managed-health-services", "filing_unit": "medicaid_plan" }, { "filing_id": "f0126", "parent_org": "Centene", "plan_name": "Ambetter Health (Indiana / MHS Indiana marketplace)", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "IN", "reporting_period": "CY2025", "std_total": 56928, "std_approved": 42933, "std_denied": 13995, "std_denial_rate": 24.58, "std_denial_rate_printed": 24.58, "std_appeals_total": 1884, "std_appeals_overturned": 684, "std_appeal_overturn_rate": 36.31, "exp_total": 2976, "exp_approved": 2224, "exp_denied": 752, "exp_denial_rate": 25.27, "ext_review_approved": null, "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.ambetterhealth.com/content/dam/centene/mhsindiana/Ambetter/PDFs/IN_MKT_AH_35065_MetricsSummary_R.pdf", "source_segment": "w3_qhp", "extraction_note": "Issuer ID 35065; document prints plan name as 'Ambetter Health' with no explicit state label, but URL/site path confirms Indiana (MHS Indiana). Expedited appeals: 148 total, 86 overturned (58.11%). Expedited TAT printed in days (mean 1, median 0); converted to hours (24h/0h) - native unit was days.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:IN:35065", "filing_unit": "qhp_issuer" }, { "filing_id": "f0163", "parent_org": "Centene", "plan_name": "MHS Indiana - Hoosier Healthwise", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": "CY2025", "std_total": 34618, "std_approved": 27451, "std_denied": 7167, "std_denial_rate": 20.7, "std_denial_rate_printed": null, "std_appeals_total": 721, "std_appeals_overturned": 221, "std_appeal_overturn_rate": 30.65, "exp_total": 427, "exp_approved": 374, "exp_denied": 53, "exp_denial_rate": 12.41, "ext_review_approved": 4776, "std_tat_mean_days": 2, "std_tat_median_days": 1, "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.mhsindiana.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/IN_HHealthWise_Medicaid_HHW_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "Expedited TAT printed as 0 days mean and median (whole-day rounding).", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:managed-health-services", "filing_unit": "medicaid_plan" }, { "filing_id": "f0314", "parent_org": "Humana", "plan_name": "Humana Healthy Horizons in Indiana", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": "2025", "std_total": 26092, "std_approved": 22791, "std_denied": 3301, "std_denial_rate": 12.65, "std_denial_rate_printed": 12.65, "std_appeals_total": 991, "std_appeals_overturned": 52, "std_appeal_overturn_rate": 5.25, "exp_total": 1722, "exp_approved": 1323, "exp_denied": 399, "exp_denial_rate": 23.17, "ext_review_approved": 10, "std_tat_mean_days": 4, "std_tat_median_days": 1, "exp_tat_mean_hours": 47, "exp_tat_median_hours": 11, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.humana.com/is/content/humana/Humana_IN_Prior_Auth_Metrics_PlanYear2025pdf", "source_segment": "w5_humana", "extraction_note": "parsed from the published template by pipeline.preauth.extract (humana)", "source_sha256": "5e05828b1668b1ee5a3992eefdc8fcce280a18f70ef65dd5720918b67ac91662", "service_list_url": "https://provider.humana.com/MedicaidPAL", "service_list_items": null, "entity_id": "mcd:IN:humana-healthy-horizons-of-indiana", "filing_unit": "medicaid_plan" }, { "filing_id": "f0212", "parent_org": "Elevance Health", "plan_name": "", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": null, "std_total": 102444, "std_approved": 93212, "std_denied": 9232, "std_denial_rate": 9.01, "std_denial_rate_printed": null, "std_appeals_total": 2547, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 1692, "exp_approved": 1465, "exp_denied": 227, "exp_denial_rate": 13.42, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1, "exp_tat_mean_hours": 1, "exp_tat_median_hours": 1, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.anthem.com/content/dam/digital/docs/anthem/medicaid/in/in_PAMetrics_HCC_EN.pdf", "source_segment": "w5_numbered", "extraction_note": "parsed from the CMS numbered-item template by pipeline.preauth.extract (numbered)", "source_sha256": "c05f2551883d796549b3bfd7da9373b6b4159b254bff02356c8ca13ab4a1cc59", "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:anthem-blue-cross-and-blue-shield", "filing_unit": "medicaid_plan" }, { "filing_id": "f0214", "parent_org": "Elevance Health", "plan_name": "", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": null, "std_total": 425335, "std_approved": 390769, "std_denied": 34566, "std_denial_rate": 8.13, "std_denial_rate_printed": null, "std_appeals_total": 1567, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 6498, "exp_approved": 5721, "exp_denied": 777, "exp_denial_rate": 11.96, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1, "exp_tat_mean_hours": 1, "exp_tat_median_hours": 1, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.anthem.com/content/dam/digital/docs/anthem/medicaid/in/in_PAMetrics_HIP_EN.pdf", "source_segment": "w5_numbered", "extraction_note": "parsed from the CMS numbered-item template by pipeline.preauth.extract (numbered)", "source_sha256": "2199793909d3b168305cb5d1d31a6fd28871358a4a73e6e3e4a88b966a8a2533", "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:anthem-blue-cross-and-blue-shield", "filing_unit": "medicaid_plan" }, { "filing_id": "f0503", "parent_org": "UnitedHealth Group", "plan_name": "Indiana Hoosier Care Connect", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": "CY2025", "std_total": 6248, "std_approved": 5788, "std_denied": 460, "std_denial_rate": 7.36, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 20, "std_appeal_overturn_rate": null, "exp_total": 815, "exp_approved": 798, "exp_denied": 17, "exp_denial_rate": 2.09, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1.8, "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": null, "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:unitedhealthcare-community-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0213", "parent_org": "Elevance Health", "plan_name": "", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": null, "std_total": 122312, "std_approved": 114061, "std_denied": 8251, "std_denial_rate": 6.75, "std_denial_rate_printed": null, "std_appeals_total": 1851, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 1078, "exp_approved": 921, "exp_denied": 157, "exp_denial_rate": 14.56, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1, "exp_tat_mean_hours": 1, "exp_tat_median_hours": 1, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.anthem.com/content/dam/digital/docs/anthem/medicaid/in/in_PAMetrics_HHW_EN.pdf", "source_segment": "w5_numbered", "extraction_note": "parsed from the CMS numbered-item template by pipeline.preauth.extract (numbered)", "source_sha256": "a9bb619d6965e1edbffaff6d056b1856f130066941d887e6f90fc653d76f68ed", "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:anthem-blue-cross-and-blue-shield", "filing_unit": "medicaid_plan" }, { "filing_id": "f0335", "parent_org": "Indiana Family and Social Services Administration", "plan_name": "Indiana Health Coverage Programs (fee-for-service)", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "IN", "reporting_period": "01/01/2025 through 12/31/2025", "std_total": 204568, "std_approved": 179701, "std_denied": 10442, "std_denial_rate": 5.1, "std_denial_rate_printed": 5.1, "std_appeals_total": 583, "std_appeals_overturned": 162, "std_appeal_overturn_rate": 27.79, "exp_total": 2174, "exp_approved": 1844, "exp_denied": 66, "exp_denial_rate": 3.04, "ext_review_approved": 40268, "std_tat_mean_days": 2.11, "std_tat_median_days": 2, "exp_tat_mean_hours": 19.19, "exp_tat_median_hours": 9, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; error:exp_counts_reconcile", "error_count": 2, "warn_count": 0, "source_url": "https://www.in.gov/medicaid/providers/files/Acentra-Health-Prior-Authorization-Metrics-Report-2025.xlsx", "source_segment": "w5_states", "extraction_note": "Transcribed from the Total row of the CMS_INTEROP_2025 sheet. Indiana counts service LINES, not requests, and reports a third outcome -- partial approval (14,426 standard, 264 expedited) -- which is neither an approval nor a denial here and is excluded from both, so approved + denied falls short of the printed total. Appeals are fair hearings decided by an ALJ, a narrower definition than most payers use.", "source_sha256": "238ca0279a55d798533333ef778189e41a701f47baeb1c2d315581bdcf754038", "service_list_url": "https://www.in.gov/medicaid/providers/clinical-services/prior-authorization/prior-authorization-metrics-reporting/", "service_list_items": 31, "entity_id": "ffs:IN", "filing_unit": "ffs_state" }, { "filing_id": "f0504", "parent_org": "UnitedHealth Group", "plan_name": "Indiana PathWays for Aging", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": "CY2025", "std_total": 54990, "std_approved": 52805, "std_denied": 2185, "std_denial_rate": 3.97, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 37, "std_appeal_overturn_rate": null, "exp_total": 339, "exp_approved": 299, "exp_denied": 40, "exp_denial_rate": 11.8, "ext_review_approved": null, "std_tat_mean_days": 0, "std_tat_median_days": 0.6, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 12, "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": null, "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:unitedhealthcare-community-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0215", "parent_org": "Elevance Health", "plan_name": "", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "IN", "reporting_period": null, "std_total": 403669, "std_approved": 397672, "std_denied": 5997, "std_denial_rate": 1.49, "std_denial_rate_printed": null, "std_appeals_total": 919, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 2085, "exp_approved": 1853, "exp_denied": 232, "exp_denial_rate": 11.13, "ext_review_approved": null, "std_tat_mean_days": 7, "std_tat_median_days": 6, "exp_tat_mean_hours": 1, "exp_tat_median_hours": 1, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.anthem.com/content/dam/digital/docs/anthem/medicaid/in/in_PAMetrics_Pathways_EN.pdf", "source_segment": "w5_numbered", "extraction_note": "parsed from the CMS numbered-item template by pipeline.preauth.extract (numbered)", "source_sha256": "6d5e737b85520fae0d145748b51591908718044185687488c0301586f4532b3b", "service_list_url": null, "service_list_items": null, "entity_id": "mcd:IN:anthem-blue-cross-and-blue-shield", "filing_unit": "medicaid_plan" } ] }