{ "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": "f0509", "parent_org": "UnitedHealth Group", "plan_name": "Massachusetts Senior Care Options", "contract_id": null, "coverage_type": "Medicare-Medicaid Plan", "state": "MA", "reporting_period": "CY2025", "std_total": 84, "std_approved": 56, "std_denied": 28, "std_denial_rate": 33.33, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 0, "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": 0, "std_tat_median_days": 0.7, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "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": "No expedited row present in source.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H4610", "filing_unit": "ma_contract" }, { "filing_id": "f0508", "parent_org": "UnitedHealth Group", "plan_name": "Massachusetts One Care", "contract_id": null, "coverage_type": "Medicare-Medicaid Plan", "state": "MA", "reporting_period": "CY2025", "std_total": 20248, "std_approved": 15708, "std_denied": 4540, "std_denial_rate": 22.42, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 1, "std_appeal_overturn_rate": null, "exp_total": 54, "exp_approved": 49, "exp_denied": 5, "exp_denial_rate": 9.26, "ext_review_approved": null, "std_tat_mean_days": 0, "std_tat_median_days": 0.6, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 146.4, "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 median of 146 hours far exceeds the 72-hour expedited standard.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H4610", "filing_unit": "ma_contract" }, { "filing_id": "f0192", "parent_org": "Commonwealth of Massachusetts", "plan_name": "Calendar Year 2025 Prior Authorization Metrics (program not named in document)", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "MA", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 14.56, "std_denial_rate_printed": 14.56, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 29.51, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 21.81, "ext_review_approved": null, "std_tat_mean_days": 4.21, "std_tat_median_days": 1.96, "exp_tat_mean_hours": 32, "exp_tat_median_hours": 2, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://www.mass.gov/doc/calendar-year-2025-prior-authorization-metrics-0/download", "source_segment": "sweep", "extraction_note": "LOW-CONFIDENCE ATTRIBUTION: the document text contains only the metrics table, with no title block, organization, program name, or reporting period. Org/state/coverage attributed from the mass.gov hosting and file title alone. Percentages only.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ffs:MA", "filing_unit": "ffs_state" }, { "filing_id": "f0377", "parent_org": "Mass General Brigham", "plan_name": "Mass General Brigham Advantage PPO", "contract_id": "H9485", "coverage_type": "Medicare Advantage", "state": "MA", "reporting_period": "CY2025", "std_total": 11482, "std_approved": 10137, "std_denied": 1345, "std_denial_rate": 11.71, "std_denial_rate_printed": null, "std_appeals_total": 173, "std_appeals_overturned": 121, "std_appeal_overturn_rate": 69.94, "exp_total": 1121, "exp_approved": 1035, "exp_denied": 86, "exp_denial_rate": 7.67, "ext_review_approved": 0, "std_tat_mean_days": 4.67, "std_tat_median_days": 1.04, "exp_tat_mean_hours": 45, "exp_tat_median_hours": 31, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://massgeneralbrighamadvantage.org/member-resources/ma-pa-metrics", "source_segment": "regional", "extraction_note": "Standard TAT printed as composite days+hours and converted.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H9485", "filing_unit": "ma_contract" }, { "filing_id": "f0378", "parent_org": "Mass General Brigham", "plan_name": "Mass General Brigham Advantage Secure HMO-POS", "contract_id": "H6847", "coverage_type": "Medicare Advantage", "state": "MA", "reporting_period": "CY2025", "std_total": 1954, "std_approved": 1739, "std_denied": 215, "std_denial_rate": 11, "std_denial_rate_printed": null, "std_appeals_total": 37, "std_appeals_overturned": 25, "std_appeal_overturn_rate": 67.57, "exp_total": 181, "exp_approved": 172, "exp_denied": 9, "exp_denial_rate": 4.97, "ext_review_approved": 0, "std_tat_mean_days": 7.29, "std_tat_median_days": 1.04, "exp_tat_mean_hours": 36, "exp_tat_median_hours": 30, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://massgeneralbrighamadvantage.org/member-resources/ma-pa-metrics", "source_segment": "regional", "extraction_note": "Standard TAT printed as composite days+hours and converted.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H6847", "filing_unit": "ma_contract" }, { "filing_id": "f0379", "parent_org": "Mass General Brigham", "plan_name": "Mass General Brigham Health Plan - MGB ACO (MassHealth)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MA", "reporting_period": "CY2025", "std_total": 41373, "std_approved": 37180, "std_denied": 4193, "std_denial_rate": 10.13, "std_denial_rate_printed": null, "std_appeals_total": 208, "std_appeals_overturned": 51, "std_appeal_overturn_rate": 24.52, "exp_total": 9489, "exp_approved": 9170, "exp_denied": 319, "exp_denial_rate": 3.36, "ext_review_approved": 1, "std_tat_mean_days": 5.21, "std_tat_median_days": 1.38, "exp_tat_mean_hours": 55, "exp_tat_median_hours": 29, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://massgeneralbrighamhealthplan.org/members/mgb-aco/medicaid-pa-metrics", "source_segment": "regional", "extraction_note": "Composite TAT converted.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:MA:mass-general-brigham-health-plan-with-mass-general-brigham-a", "filing_unit": "medicaid_plan" }, { "filing_id": "f0443", "parent_org": "Point32Health", "plan_name": "Tufts Health Together Managed Care Organization (MCO)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MA", "reporting_period": "CY2025", "std_total": 2058, "std_approved": 1906, "std_denied": 152, "std_denial_rate": 7.39, "std_denial_rate_printed": 7.4, "std_appeals_total": null, "std_appeals_overturned": 1, "std_appeal_overturn_rate": null, "exp_total": 229, "exp_approved": 195, "exp_denied": 34, "exp_denial_rate": 14.85, "ext_review_approved": null, "std_tat_mean_days": 4.9, "std_tat_median_days": 3.9, "exp_tat_mean_hours": 13.6, "exp_tat_median_hours": 4.8, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.tuftsmedicarepreferred.org/pa-cms-ma-together-report", "source_segment": "w3_newengland", "extraction_note": "Third of three sub-plan tables on the shared Tufts Health Together report page (see Cambridge Health Alliance row note). Appeals-filed total not separately published.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:MA:tufts-health-together", "filing_unit": "medicaid_plan" }, { "filing_id": "f0240", "parent_org": "Fallon Health", "plan_name": "Fallon Health – Atrius Health Care Collaborative (365 Care)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MA", "reporting_period": "CY2025", "std_total": 18169, "std_approved": 16929, "std_denied": 1240, "std_denial_rate": 6.82, "std_denial_rate_printed": 7, "std_appeals_total": 171, "std_appeals_overturned": 129, "std_appeal_overturn_rate": 75.44, "exp_total": 2705, "exp_approved": 2619, "exp_denied": 86, "exp_denial_rate": 3.18, "ext_review_approved": null, "std_tat_mean_days": 3, "std_tat_median_days": 0, "exp_tat_mean_hours": 6, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.fallonhealth.org/en/atriushealth/pa-reporting", "source_segment": "w3_newengland", "extraction_note": "Page title is 'Prior authorization transparency and reporting' for 'Fallon Health-Atrius Health Care Collaborative'; the exact plan/product is not named beyond this on the page. This is very likely the Fallon 365 Care MassHealth ACO Partnership Plan product, so coverage_type Medicaid Managed Care is an inference from context, not a printed label — treat with caution. All denial/overturn percentages (7%, 3%, 75%) are printed on the page next to the counts, verified verbatim (not calculated by the collector).", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:MA:fallon-365-care", "filing_unit": "medicaid_plan" }, { "filing_id": "f0445", "parent_org": "Point32Health", "plan_name": "Tufts Health Together with UMass Memorial Health", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MA", "reporting_period": "CY2025", "std_total": 6367, "std_approved": 6036, "std_denied": 331, "std_denial_rate": 5.2, "std_denial_rate_printed": 5.2, "std_appeals_total": null, "std_appeals_overturned": 10, "std_appeal_overturn_rate": null, "exp_total": 512, "exp_approved": 441, "exp_denied": 71, "exp_denial_rate": 13.87, "ext_review_approved": null, "std_tat_mean_days": 4.6, "std_tat_median_days": 4.9, "exp_tat_mean_hours": 31.5, "exp_tat_median_hours": 18.5, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.tuftsmedicarepreferred.org/pa-cms-ma-together-report", "source_segment": "w3_newengland", "extraction_note": "One of three sub-plan tables on the shared Tufts Health Together report page (see Cambridge Health Alliance row note). Appeals-filed total not separately published.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:MA:tufts-health-together-with-umass-memorial-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0032", "parent_org": "Blue Cross Blue Shield of Massachusetts", "plan_name": "BCBSMA Medicare Advantage HMO", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "MA", "reporting_period": "1/1/2025 - 12/31/2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 4.61, "std_denial_rate_printed": 4.61, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 12.09, "ext_review_approved": null, "std_tat_mean_days": 1.84, "std_tat_median_days": 0, "exp_tat_mean_hours": 22.32, "exp_tat_median_hours": 0, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://home.bluecrossma.com/collateral/sites/g/files/csphws1571/files/acquiadam-assets/55-PAREPORT-2025-prior-authorization-metrics-reporting.pdf", "source_segment": "w5_states", "extraction_note": "Percentages only, split HMO/PPO. Approved-after-appeal printed as 56.57% of appeals; no counts anywhere. Expedited TAT printed in days, converted to hours. The document that four earlier fetch attempts received 403 for; it served normally on 25 Aug 2026, so the recorded gap is resolved by this row.", "source_sha256": "381ac56f211b9d6cf94393a57c95507f04c53c7ed937a9672e48cdebff07d27b", "service_list_url": null, "service_list_items": null, "entity_id": "ma:H2261", "filing_unit": "ma_contract" }, { "filing_id": "f0441", "parent_org": "Point32Health", "plan_name": "Tufts Health One Care", "contract_id": null, "coverage_type": "Medicare-Medicaid Plan", "state": "MA", "reporting_period": "CY2025", "std_total": 9942, "std_approved": 9497, "std_denied": 445, "std_denial_rate": 4.48, "std_denial_rate_printed": 4.5, "std_appeals_total": null, "std_appeals_overturned": 31, "std_appeal_overturn_rate": null, "exp_total": 686, "exp_approved": 612, "exp_denied": 74, "exp_denial_rate": 10.79, "ext_review_approved": 0, "std_tat_mean_days": 4, "std_tat_median_days": 2.7, "exp_tat_mean_hours": 7.6, "exp_tat_median_hours": 1.3, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.tuftsmedicarepreferred.org/pa-cms-one-care-report", "source_segment": "w3_newengland", "extraction_note": "Verified % signs are literally printed on page next to counts (e.g. 'Request approved 9,497 9,942 95.5%'), not calculated. Document also prints 'approved after appeal: 31 (0.3%)' where the 0.3% denominator is total standard requests (9,942), not appeals filed — appeals_total (number of appeals filed) is not separately published, so std_appeals_total and std_appeal_overturn_pct are omitted to avoid implying an appeals-filed denominator. 'Approved after extension' = 0 for both standard and expedited per document; recorded once under ext_review_approved (standard bucket).", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H9907", "filing_unit": "ma_contract" }, { "filing_id": "f0033", "parent_org": "Blue Cross Blue Shield of Massachusetts", "plan_name": "BCBSMA Medicare Advantage PPO", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "MA", "reporting_period": "1/1/2025 - 12/31/2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 4.42, "std_denial_rate_printed": 4.42, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 10.83, "ext_review_approved": null, "std_tat_mean_days": 1.28, "std_tat_median_days": 0, "exp_tat_mean_hours": 16.32, "exp_tat_median_hours": 0, "reports_counts": false, "quality_flags": "info:appeals_not_reported; info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://home.bluecrossma.com/collateral/sites/g/files/csphws1571/files/acquiadam-assets/55-PAREPORT-2025-prior-authorization-metrics-reporting.pdf", "source_segment": "w5_states", "extraction_note": "Percentages only, split HMO/PPO. Approved-after-appeal printed as 49.67% of appeals; no counts anywhere. Expedited TAT printed in days, converted to hours. The document that four earlier fetch attempts received 403 for; it served normally on 25 Aug 2026, so the recorded gap is resolved by this row.", "source_sha256": "381ac56f211b9d6cf94393a57c95507f04c53c7ed937a9672e48cdebff07d27b", "service_list_url": null, "service_list_items": null, "entity_id": "ma:H2261", "filing_unit": "ma_contract" }, { "filing_id": "f0444", "parent_org": "Point32Health", "plan_name": "Tufts Health Together with Cambridge Health Alliance (CHA)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "MA", "reporting_period": "CY2025", "std_total": 3526, "std_approved": 3386, "std_denied": 140, "std_denial_rate": 3.97, "std_denial_rate_printed": 4, "std_appeals_total": null, "std_appeals_overturned": 2, "std_appeal_overturn_rate": null, "exp_total": 152, "exp_approved": 132, "exp_denied": 20, "exp_denial_rate": 13.16, "ext_review_approved": null, "std_tat_mean_days": 5.2, "std_tat_median_days": 3.9, "exp_tat_mean_hours": 49.5, "exp_tat_median_hours": 5.6, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.tuftsmedicarepreferred.org/pa-cms-ma-together-report", "source_segment": "w3_newengland", "extraction_note": "This single URL publishes three separate Tufts Health Together sub-plan tables (Cambridge Health Alliance, UMass Memorial Health, and the general MCO line); recorded here as three separate filing rows sharing this source_url, distinguished by plan_name. Appeals-filed total not separately published (same caveat as One Care/RITogether).", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:MA:tufts-health-together-with-cambridge-health-alliance-cha", "filing_unit": "medicaid_plan" } ] }