{ "meta": { "total": 62, "page": 1, "per_page": 50, "pages": 2, "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": "f0610", "parent_org": "VillageCare", "plan_name": "VillageCareMAX Managed Long-Term Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 62.3, "std_denial_rate_printed": 62.3, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 4.3, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 46.6, "ext_review_approved": null, "std_tat_mean_days": 7.28, "std_tat_median_days": 5, "exp_tat_mean_hours": 92.64, "exp_tat_median_hours": 24, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.villagecaremax.org/prior-authorizations-reporting", "source_segment": "ca_ny", "extraction_note": "HIGHEST DENIAL RATE IN THE DATASET: 62.3% standard, 46.6% expedited. Only 4.3% of appeals overturned. Expedited mean of 3.86 days (92.6h) far exceeds any expedited standard. Percentages only, no counts to check against.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:villagecaremax", "filing_unit": "medicaid_plan" }, { "filing_id": "f0250", "parent_org": "Hamaspik", "plan_name": "Hamaspik Medicare Choice (MAP - Medicaid side)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 52, "std_denial_rate_printed": 52, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 8, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 7.84, "std_tat_median_days": 3.59, "exp_tat_mean_hours": null, "exp_tat_median_hours": null, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.hamaspik.com/priorauthdata?hsLang=en", "source_segment": "w3_ky_nc_ms_ny", "extraction_note": "MAP = Medicaid Advantage Plus; this column is the Medicaid-side reporting for Hamaspik's dual-eligible integrated plan (the Medicare-side is reported separately as 'Hamaspik Medicare Select'). Expedited approved and denied are BOTH printed as 0%, and no expedited turnaround time is shown at all - this most likely reflects zero expedited-request volume for this plan rather than a measured 0% denial rate; recorded as printed, flagged rather than omitted or treated as null. Percentages only, no counts. 'Extended timeframe approved' (9%) not stored - field expects a count.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:hamaspik-map", "filing_unit": "medicaid_plan" }, { "filing_id": "f0249", "parent_org": "Hamaspik", "plan_name": "Hamaspik Choice (MLTC)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 49, "std_denial_rate_printed": 49, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 15, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 16, "ext_review_approved": null, "std_tat_mean_days": 7.59, "std_tat_median_days": 4.28, "exp_tat_mean_hours": 101.28, "exp_tat_median_hours": 61.44, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:high_denial_rate; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.hamaspik.com/priorauthdata?hsLang=en", "source_segment": "w3_ky_nc_ms_ny", "extraction_note": "Source page's turnaround table header labels both standard and expedited columns '(days)'; expedited mean/median (4.22d / 2.56d as printed) were converted to hours (101.28 / 61.44). Percentages only ('aggregated for all items & services'), no total request counts published. Page's 'Extended timeframe approved' figure (15%) not stored - field expects a count, not a percentage.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:hamaspik-choice-mltc", "filing_unit": "medicaid_plan" }, { "filing_id": "f0604", "parent_org": "Univera Healthcare", "plan_name": "Univera Healthcare Medicare D-SNP (HMO)", "contract_id": "H7524", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 118, "std_approved": 75, "std_denied": 43, "std_denial_rate": 36.44, "std_denial_rate_printed": 36.4, "std_appeals_total": 3, "std_appeals_overturned": 1, "std_appeal_overturn_rate": 33.33, "exp_total": 3, "exp_approved": 3, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 2.5, "std_tat_median_days": 2, "exp_tat_mean_hours": 36, "exp_tat_median_hours": 45.6, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/univerametrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Dual-eligible SNP; coded Medicare Advantage. 63.6% standard approval on a very small base (118 requests). Same shared-contract-ID caveat.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H7524", "filing_unit": "ma_contract" }, { "filing_id": "f0237", "parent_org": "Excellus BlueCross BlueShield", "plan_name": "Excellus BCBS Medicare D-SNP (HMO)", "contract_id": "H7524", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 2327, "std_approved": 1645, "std_denied": 682, "std_denial_rate": 29.31, "std_denial_rate_printed": 29.3, "std_appeals_total": 27, "std_appeals_overturned": 6, "std_appeal_overturn_rate": 22.22, "exp_total": 29, "exp_approved": 24, "exp_denied": 5, "exp_denial_rate": 17.24, "ext_review_approved": null, "std_tat_mean_days": 1.8, "std_tat_median_days": 1, "exp_tat_mean_hours": 16.8, "exp_tat_median_hours": 19.2, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/excellusmetrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Contract H7524. Dual-eligible SNP; coded Medicare Advantage. 70.7% standard approval is far below the plan's other Medicare lines. Only 27 appeals against 682 denials.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H7524", "filing_unit": "ma_contract" }, { "filing_id": "f0612", "parent_org": "VillageCare", "plan_name": "VillageCareMAX Total Advantage (D-SNP) - Medicaid requests", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 28.6, "std_denial_rate_printed": 28.6, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 13.5, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 15.7, "ext_review_approved": null, "std_tat_mean_days": 4.84, "std_tat_median_days": 3, "exp_tat_mean_hours": 20.88, "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://www.villagecaremax.org/prior-authorizations-reporting", "source_segment": "ca_ny", "extraction_note": "Percentages only. Expedited TAT converted days->hours.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:villagecaremax", "filing_unit": "medicaid_plan" }, { "filing_id": "f0258", "parent_org": "Healthfirst", "plan_name": "Child Health Plus", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "NY", "reporting_period": null, "std_total": 28487, "std_approved": 20433, "std_denied": 8054, "std_denial_rate": 28.27, "std_denial_rate_printed": 28, "std_appeals_total": 869, "std_appeals_overturned": 27, "std_appeal_overturn_rate": 3.11, "exp_total": 513, "exp_approved": 302, "exp_denied": 211, "exp_denial_rate": 41.13, "ext_review_approved": 0, "std_tat_mean_days": 2.11, "std_tat_median_days": 1, "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://assets.healthfirst.org/pdf_loaG4tm0EnVO/2026interoperability-chp-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "f6dcdd4fcda881d1f86b4146e031745e2e67953602943d7f674249e0d7c8633d", "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0332", "parent_org": "Independent Health", "plan_name": "Independent Health Medicaid, Essential and CHP (combined)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 36266, "std_approved": 26040, "std_denied": 10226, "std_denial_rate": 28.2, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 191, "std_appeal_overturn_rate": null, "exp_total": 3683, "exp_approved": 3424, "exp_denied": 259, "exp_denial_rate": 7.03, "ext_review_approved": 269, "std_tat_mean_days": 2.28, "std_tat_median_days": 1, "exp_tat_mean_hours": 2.52, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.independenthealth.com/content/dam/independenthealth/individuals-and-families/my-health/prior-authorization-metrics/documents/ih-medicaid-essential-chp-plans.pdf", "source_segment": "regional", "extraction_note": "Single filing covering three distinct lines of business reported in aggregate; cannot be split.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:independent-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0516", "parent_org": "UnitedHealth Group", "plan_name": "New York Child Health Plus", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 1650, "std_approved": 1213, "std_denied": 437, "std_denial_rate": 26.48, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 1, "std_appeal_overturn_rate": null, "exp_total": 30, "exp_approved": 29, "exp_denied": 1, "exp_denial_rate": 3.33, "ext_review_approved": null, "std_tat_mean_days": 0, "std_tat_median_days": 1.3, "exp_tat_mean_hours": 96, "exp_tat_median_hours": 144, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicaid-2025.pdf", "source_segment": "wave2", "extraction_note": "Expedited mean 96h and median 144h both far exceed the 72-hour standard.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0251", "parent_org": "Hamaspik", "plan_name": "Hamaspik Medicare Select (H0034 D-SNP & MAP Medicare, combined)", "contract_id": "H0034", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 26, "std_denial_rate_printed": 26, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 54, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 20, "ext_review_approved": null, "std_tat_mean_days": 3.55, "std_tat_median_days": 2, "exp_tat_mean_hours": 37.68, "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.hamaspik.com/priorauthdata?hsLang=en", "source_segment": "w3_ky_nc_ms_ny", "extraction_note": "Source page reports this column as 'H0034 DSNP & MAP Medicare' - the H0034 D-SNP contract combined with the Medicare-side reporting of Hamaspik's Medicaid Advantage Plus (MAP) dual product; the document does not split them, both are Medicare Advantage-type lines, so coverage_type is kept as Medicare Advantage rather than 'Multiple (combined)'. Expedited turnaround printed in days (1.57d mean / 1d median); converted to hours. Percentages only, no counts. 'Extended timeframe approved' (50%) not stored - field expects a count.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H0034", "filing_unit": "ma_contract" }, { "filing_id": "f0230", "parent_org": "EmblemHealth", "plan_name": "EmblemHealth Medicaid and HARP (combined)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 115230, "std_approved": 89358, "std_denied": 25872, "std_denial_rate": 22.45, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 546, "std_appeal_overturn_rate": null, "exp_total": 5302, "exp_approved": 4574, "exp_denied": 728, "exp_denial_rate": 13.73, "ext_review_approved": 196, "std_tat_mean_days": 2.1, "std_tat_median_days": null, "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.emblemhealth.com/providers/clinical-corner/um-and-medical-management/pre-authorization-list/preauthorization-metrics", "source_segment": "regional", "extraction_note": "Printed standard median 57.0 against mean 2.1 - 27x, clearly a different unit or a data error.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:hip-combined", "filing_unit": "medicaid_plan" }, { "filing_id": "f0518", "parent_org": "UnitedHealth Group", "plan_name": "New York Medicaid Advantage", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 76049, "std_approved": 59002, "std_denied": 17047, "std_denial_rate": 22.42, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 94, "std_appeal_overturn_rate": null, "exp_total": 1807, "exp_approved": 1619, "exp_denied": 188, "exp_denial_rate": 10.4, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1.3, "exp_tat_mean_hours": 24, "exp_tat_median_hours": 127.2, "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": "Expedited median 127 hours far exceeds the 72-hour standard.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:molina-healthcare-of-new-york", "filing_unit": "medicaid_plan" }, { "filing_id": "f0382", "parent_org": "MetroPlus Health Plan", "plan_name": "MetroPlus Managed Long Term Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 4154, "std_approved": 3333, "std_denied": 821, "std_denial_rate": 19.76, "std_denial_rate_printed": 19.76, "std_appeals_total": 27, "std_appeals_overturned": 2, "std_appeal_overturn_rate": 7.41, "exp_total": 25, "exp_approved": 20, "exp_denied": 5, "exp_denial_rate": 20, "ext_review_approved": 10, "std_tat_mean_days": 0.98, "std_tat_median_days": 0.06, "exp_tat_mean_hours": 23.52, "exp_tat_median_hours": 13.68, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://metroplus.org/wp-content/uploads/2026/07/MLTC_HA-851_20260622.xlsx", "source_segment": "w5_metroplus", "extraction_note": "Parsed from MetroPlus's published workbook (the CMS template as an xlsx). Percentages are stored as fractions in the sheet and converted. Both turnaround rows are in days; expedited converted to hours. The workbook the earlier crawl recorded as an unreadable binary gap -- now read.", "source_sha256": "fa21ac29bac84da499592b5d53079a77dc1c69674fce3c969fc6d251014c19f8", "service_list_url": "https://metroplus.org/members/provider-authorization/", "service_list_items": null, "entity_id": "mcd:NY:metroplus", "filing_unit": "medicaid_plan" }, { "filing_id": "f0265", "parent_org": "Healthfirst", "plan_name": "Medicaid Managed Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": null, "std_total": 750763, "std_approved": 603021, "std_denied": 147742, "std_denial_rate": 19.68, "std_denial_rate_printed": 20, "std_appeals_total": 12073, "std_appeals_overturned": 1725, "std_appeal_overturn_rate": 14.29, "exp_total": 10464, "exp_approved": 6231, "exp_denied": 4233, "exp_denial_rate": 40.45, "ext_review_approved": 2313, "std_tat_mean_days": 1.62, "std_tat_median_days": 0, "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://assets.healthfirst.org/pdf_9KLIISxzyksl/2026interoperability-medicaid-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "a86c08c247d033ebfae83038e41e8fa08db3dcd639c4fbce5a12422a9fd80113", "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:healthfirst", "filing_unit": "medicaid_plan" }, { "filing_id": "f0381", "parent_org": "MetroPlus Health Plan", "plan_name": "MetroPlus HARP", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 6277, "std_approved": 5083, "std_denied": 1194, "std_denial_rate": 19.02, "std_denial_rate_printed": 19.02, "std_appeals_total": 571, "std_appeals_overturned": 205, "std_appeal_overturn_rate": 35.9, "exp_total": 36, "exp_approved": 28, "exp_denied": 8, "exp_denial_rate": 22.22, "ext_review_approved": 34, "std_tat_mean_days": 3.03, "std_tat_median_days": 1.98, "exp_tat_mean_hours": 35.52, "exp_tat_median_hours": 7.92, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://metroplus.org/wp-content/uploads/2026/07/HARP_HA-851_20260622.xlsx", "source_segment": "w5_metroplus", "extraction_note": "Parsed from MetroPlus's published workbook (the CMS template as an xlsx). Percentages are stored as fractions in the sheet and converted. Both turnaround rows are in days; expedited converted to hours. The workbook the earlier crawl recorded as an unreadable binary gap -- now read.", "source_sha256": "8c4856901a1a7ccbfef6873ef5c4aa873b0794464e09d6e2b3ad7bc64236e22f", "service_list_url": "https://metroplus.org/members/provider-authorization/", "service_list_items": null, "entity_id": "mcd:NY:metroplus", "filing_unit": "medicaid_plan" }, { "filing_id": "f0050", "parent_org": "CDPHP", "plan_name": "CDPHP Child Health Plus", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 455, "std_approved": 373, "std_denied": 82, "std_denial_rate": 18.02, "std_denial_rate_printed": null, "std_appeals_total": 15, "std_appeals_overturned": 3, "std_appeal_overturn_rate": 20, "exp_total": 47, "exp_approved": 46, "exp_denied": 1, "exp_denial_rate": 2.13, "ext_review_approved": 2, "std_tat_mean_days": 7, "std_tat_median_days": 5, "exp_tat_mean_hours": 35, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.cdphp.com/-/media/files/otherpdfs/interoperabiity-auth-study-chp.pdf", "source_segment": "regional", "extraction_note": "TAT units unlabeled; inferred.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0229", "parent_org": "EmblemHealth", "plan_name": "EmblemHealth Child Health Plus", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 6070, "std_approved": 4986, "std_denied": 1084, "std_denial_rate": 17.86, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 53, "std_appeal_overturn_rate": null, "exp_total": 122, "exp_approved": 101, "exp_denied": 21, "exp_denial_rate": 17.21, "ext_review_approved": 3, "std_tat_mean_days": 2.1, "std_tat_median_days": null, "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.emblemhealth.com/providers/clinical-corner/um-and-medical-management/pre-authorization-list/preauthorization-metrics", "source_segment": "regional", "extraction_note": "Unit ambiguity; appeals denominator is all requests.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0611", "parent_org": "VillageCare", "plan_name": "VillageCareMAX Medicare (all plans, aggregated)", "contract_id": null, "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 17.8, "std_denial_rate_printed": 17.8, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 32.9, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 3.5, "ext_review_approved": null, "std_tat_mean_days": 6.53, "std_tat_median_days": 5, "exp_tat_mean_hours": 17.76, "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://www.villagecaremax.org/prior-authorizations-reporting", "source_segment": "ca_ny", "extraction_note": "Percentages only. Expedited TAT converted days->hours.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H2168", "filing_unit": "ma_contract" }, { "filing_id": "f0517", "parent_org": "UnitedHealth Group", "plan_name": "New York Essential Plan Program", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 18664, "std_approved": 15550, "std_denied": 3114, "std_denial_rate": 16.68, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 39, "std_appeal_overturn_rate": null, "exp_total": 196, "exp_approved": 153, "exp_denied": 43, "exp_denial_rate": 21.94, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1.3, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 110.4, "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": "Basic Health Program mapped to Medicaid Managed Care. Expedited median 110h exceeds the 72-hour standard.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:unitedhealthcare", "filing_unit": "medicaid_plan" }, { "filing_id": "f0400", "parent_org": "Molina Healthcare", "plan_name": "Molina Healthcare of New York Medicaid", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 16, "std_denial_rate_printed": 16, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 30, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 9, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 3, "exp_tat_mean_hours": 31, "exp_tat_median_hours": 25, "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/ny/medicaid/resource/utilized_mgt.aspx", "source_segment": "wave2", "extraction_note": "Rates only, no volumes.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:molina-healthcare-of-new-york", "filing_unit": "medicaid_plan" }, { "filing_id": "f0607", "parent_org": "Univera Healthcare", "plan_name": "Univera Healthcare MyHealth (MMC)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 4910, "std_approved": 4127, "std_denied": 783, "std_denial_rate": 15.95, "std_denial_rate_printed": 15.9, "std_appeals_total": 26, "std_appeals_overturned": 2, "std_appeal_overturn_rate": 7.69, "exp_total": 54, "exp_approved": 47, "exp_denied": 7, "exp_denial_rate": 12.96, "ext_review_approved": 590, "std_tat_mean_days": 1.3, "std_tat_median_days": 1.2, "exp_tat_mean_hours": 9.6, "exp_tat_median_hours": 2.4, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/univerametrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Extended review total 678, of which 590 approved.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0386", "parent_org": "MetroPlus Health Plan", "plan_name": "MetroPlus Partnership in Care (HIV SNP)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 2151, "std_approved": 1814, "std_denied": 337, "std_denial_rate": 15.67, "std_denial_rate_printed": 15.67, "std_appeals_total": 97, "std_appeals_overturned": 32, "std_appeal_overturn_rate": 32.99, "exp_total": 14, "exp_approved": 14, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": 20, "std_tat_mean_days": 2.29, "std_tat_median_days": 0.71, "exp_tat_mean_hours": 13.68, "exp_tat_median_hours": 4.8, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://metroplus.org/wp-content/uploads/2026/07/PICSNP_HA-851_20260622.xlsx", "source_segment": "w5_metroplus", "extraction_note": "Parsed from MetroPlus's published workbook (the CMS template as an xlsx). Percentages are stored as fractions in the sheet and converted. Both turnaround rows are in days; expedited converted to hours. The workbook the earlier crawl recorded as an unreadable binary gap -- now read.", "source_sha256": "c1bb9e5a627068ef4aa14d97adc0320498582b5af98b28c30f226923cb43fb22", "service_list_url": "https://metroplus.org/members/provider-authorization/", "service_list_items": null, "entity_id": "mcd:NY:metroplus", "filing_unit": "medicaid_plan" }, { "filing_id": "f0384", "parent_org": "MetroPlus Health Plan", "plan_name": "MetroPlus Medicaid Managed Care", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 52170, "std_approved": 44154, "std_denied": 8016, "std_denial_rate": 15.37, "std_denial_rate_printed": 15.37, "std_appeals_total": 2703, "std_appeals_overturned": 849, "std_appeal_overturn_rate": 31.41, "exp_total": 427, "exp_approved": 368, "exp_denied": 59, "exp_denial_rate": 13.82, "ext_review_approved": 231, "std_tat_mean_days": 2.77, "std_tat_median_days": 1.77, "exp_tat_mean_hours": 33.36, "exp_tat_median_hours": 18.24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://metroplus.org/wp-content/uploads/2026/07/MCAD_HA-851_20260622.xlsx", "source_segment": "w5_metroplus", "extraction_note": "Parsed from MetroPlus's published workbook (the CMS template as an xlsx). Percentages are stored as fractions in the sheet and converted. Both turnaround rows are in days; expedited converted to hours. The workbook the earlier crawl recorded as an unreadable binary gap -- now read.", "source_sha256": "00572b42ac07e2032a21146b8c57f2c7435a455524f92ce341d52c3443bf24d0", "service_list_url": "https://metroplus.org/members/provider-authorization/", "service_list_items": null, "entity_id": "mcd:NY:metroplus", "filing_unit": "medicaid_plan" }, { "filing_id": "f0263", "parent_org": "Healthfirst", "plan_name": "Health and Recovery Plan (HARP)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": null, "std_total": 54478, "std_approved": 46120, "std_denied": 8358, "std_denial_rate": 15.34, "std_denial_rate_printed": 15, "std_appeals_total": 958, "std_appeals_overturned": 202, "std_appeal_overturn_rate": 21.09, "exp_total": 546, "exp_approved": 356, "exp_denied": 190, "exp_denial_rate": 34.8, "ext_review_approved": 162, "std_tat_mean_days": 1.55, "std_tat_median_days": 0, "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://assets.healthfirst.org/pdf_zxaNAIe8jYN2/2026interoperability-harp-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "37b384ce65760baed8d4c1305e03d6e6b57636dde3b3131b59eff258731fbd45", "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:healthfirst", "filing_unit": "medicaid_plan" }, { "filing_id": "f0236", "parent_org": "Excellus BlueCross BlueShield", "plan_name": "Excellus BCBS Managed Medicaid (MMC)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 126221, "std_approved": 107238, "std_denied": 18983, "std_denial_rate": 15.04, "std_denial_rate_printed": 15, "std_appeals_total": 705, "std_appeals_overturned": 130, "std_appeal_overturn_rate": 18.44, "exp_total": 918, "exp_approved": 686, "exp_denied": 232, "exp_denial_rate": 25.27, "ext_review_approved": 17716, "std_tat_mean_days": 1.4, "std_tat_median_days": 1.2, "exp_tat_mean_hours": 16.8, "exp_tat_median_hours": 7.2, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/excellusmetrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Extended review total 20,067, of which 17,716 approved. Only 705 appeals against 18,983 standard denials (3.7% appeal rate).", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:excellus-health-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0235", "parent_org": "Excellus BlueCross BlueShield", "plan_name": "Excellus BCBS Child Health Plus", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 18319, "std_approved": 15667, "std_denied": 2652, "std_denial_rate": 14.48, "std_denial_rate_printed": 14.5, "std_appeals_total": 112, "std_appeals_overturned": 16, "std_appeal_overturn_rate": 14.29, "exp_total": 73, "exp_approved": 60, "exp_denied": 13, "exp_denial_rate": 17.81, "ext_review_approved": 1529, "std_tat_mean_days": 1.6, "std_tat_median_days": 1.4, "exp_tat_mean_hours": 14.4, "exp_tat_median_hours": 2.4, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/excellusmetrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Extended review total 1,768, of which 1,529 approved.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0233", "parent_org": "EmblemHealth", "plan_name": "EmblemHealth Medicare H5991", "contract_id": "H5991", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 5009, "std_approved": 4309, "std_denied": 700, "std_denial_rate": 13.97, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 50, "std_appeal_overturn_rate": null, "exp_total": 154, "exp_approved": 126, "exp_denied": 28, "exp_denial_rate": 18.18, "ext_review_approved": 4, "std_tat_mean_days": 1.9, "std_tat_median_days": null, "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.emblemhealth.com/providers/clinical-corner/um-and-medical-management/pre-authorization-list/preauthorization-metrics", "source_segment": "regional", "extraction_note": "Same unit ambiguity; printed median 15.0 against mean 1.9.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5991", "filing_unit": "ma_contract" }, { "filing_id": "f0380", "parent_org": "MetroPlus Health Plan", "plan_name": "MetroPlus Child Health Plus", "contract_id": null, "coverage_type": "CHIP Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 1861, "std_approved": 1604, "std_denied": 257, "std_denial_rate": 13.81, "std_denial_rate_printed": 13.81, "std_appeals_total": 77, "std_appeals_overturned": 16, "std_appeal_overturn_rate": 20.78, "exp_total": 6, "exp_approved": 6, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": 1, "std_tat_mean_days": 2.36, "std_tat_median_days": 1.32, "exp_tat_mean_hours": 34.32, "exp_tat_median_hours": 15.6, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://metroplus.org/wp-content/uploads/2026/07/CHP_HA-851_20260622.xlsx", "source_segment": "w5_metroplus", "extraction_note": "Parsed from MetroPlus's published workbook (the CMS template as an xlsx). Percentages are stored as fractions in the sheet and converted. Both turnaround rows are in days; expedited converted to hours. The workbook the earlier crawl recorded as an unreadable binary gap -- now read.", "source_sha256": "41a872e5aa6ee3c140e9634a41bac17ecaedf98cd4a5e558178ddd8f559565d4", "service_list_url": "https://metroplus.org/members/provider-authorization/", "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0232", "parent_org": "EmblemHealth", "plan_name": "EmblemHealth Medicare H5228", "contract_id": "H5228", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 29, "std_approved": 25, "std_denied": 4, "std_denial_rate": 13.79, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 0, "std_appeal_overturn_rate": null, "exp_total": 2, "exp_approved": 2, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": 0, "std_tat_mean_days": 2.1, "std_tat_median_days": null, "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.emblemhealth.com/providers/clinical-corner/um-and-medical-management/pre-authorization-list/preauthorization-metrics", "source_segment": "regional", "extraction_note": "Very small volumes; unit ambiguity.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5991", "filing_unit": "ma_contract" }, { "filing_id": "f0608", "parent_org": "Univera Healthcare", "plan_name": "Univera Healthcare MyHealth Plus (HARP)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 498, "std_approved": 433, "std_denied": 65, "std_denial_rate": 13.05, "std_denial_rate_printed": 13.1, "std_appeals_total": 2, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 8, "exp_approved": 8, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": 74, "std_tat_mean_days": 1.1, "std_tat_median_days": 0.9, "exp_tat_mean_hours": 4.8, "exp_tat_median_hours": 2.4, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/univerametrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Extended review total 91, of which 74 approved. 2 appeals reported; outcomes suppressed.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0415", "parent_org": "Molina Healthcare", "plan_name": "Senior Whole Health of New York - MLTSS", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 13, "std_denial_rate_printed": 13, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 16, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 13, "ext_review_approved": null, "std_tat_mean_days": 3, "std_tat_median_days": 1, "exp_tat_mean_hours": 79, "exp_tat_median_hours": 43, "reports_counts": false, "quality_flags": "info:appeals_not_reported; warn:expedited_slower_than_standard; info:percentages_only", "error_count": 0, "warn_count": 1, "source_url": "https://www.molinahealthcare.com/providers/ny/swh/forms/prior-auth-reporting.aspx", "source_segment": "national", "extraction_note": "Percentages only. Mean expedited turnaround of 79 hours exceeds the 72-hour expedited standard.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:senior-whole-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0052", "parent_org": "CDPHP", "plan_name": "CDPHP Medicaid HARP", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 1770, "std_approved": 1540, "std_denied": 230, "std_denial_rate": 12.99, "std_denial_rate_printed": null, "std_appeals_total": 24, "std_appeals_overturned": 4, "std_appeal_overturn_rate": 16.67, "exp_total": 57, "exp_approved": 57, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": 0, "std_tat_mean_days": 2.1, "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.cdphp.com/-/media/files/otherpdfs/interoperabiity-auth-study-medicaid-harp.pdf", "source_segment": "regional", "extraction_note": "Expedited row shows 57 approved (100%) yet 52 approved and 5 denied within 72 hours, contradicting 0 denials.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0234", "parent_org": "Excellus BlueCross BlueShield", "plan_name": "Excellus BCBS Blue Option Plus (HARP)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 17806, "std_approved": 15512, "std_denied": 2294, "std_denial_rate": 12.88, "std_denial_rate_printed": 12.9, "std_appeals_total": 100, "std_appeals_overturned": 10, "std_appeal_overturn_rate": 10, "exp_total": 108, "exp_approved": 99, "exp_denied": 9, "exp_denial_rate": 8.33, "ext_review_approved": 3224, "std_tat_mean_days": 1.3, "std_tat_median_days": 1, "exp_tat_mean_hours": 12, "exp_tat_median_hours": 7.2, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.excellusbcbs.com/documents/d/global/excellusmetrics2025", "source_segment": "blues", "extraction_note": "Expedited decision times were published in DAYS in this report and converted to hours (x24). Extended-review row reports a total and an approved count only, so ext_review_denied is left null (the total is given in this note rather than derived). Document is titled 'Prior Authorization Metrics 2025' and carries a publication date of January 27, 2026. Health and Recovery Program (HARP). Extended review total 3,684, of which 3,224 approved.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:excellus-health-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0264", "parent_org": "Healthfirst", "plan_name": "MLTC", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": null, "std_total": 30359, "std_approved": 26471, "std_denied": 3888, "std_denial_rate": 12.81, "std_denial_rate_printed": 13, "std_appeals_total": 309, "std_appeals_overturned": 32, "std_appeal_overturn_rate": 10.36, "exp_total": 66, "exp_approved": 50, "exp_denied": 16, "exp_denial_rate": 24.24, "ext_review_approved": 6, "std_tat_mean_days": 2.08, "std_tat_median_days": 0, "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://assets.healthfirst.org/pdf_aHN3XsN3m5OY/2026interoperability-mltc-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "b4b600b5a11be3db081f9d9207aee8eb7f834845e6d3b449df2d4f69179edfd3", "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:hamaspik-choice-mltc", "filing_unit": "medicaid_plan" }, { "filing_id": "f0051", "parent_org": "CDPHP", "plan_name": "CDPHP Managed Medicaid", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 8366, "std_approved": 7335, "std_denied": 1031, "std_denial_rate": 12.32, "std_denial_rate_printed": null, "std_appeals_total": 138, "std_appeals_overturned": 34, "std_appeal_overturn_rate": 24.64, "exp_total": 680, "exp_approved": 674, "exp_denied": 6, "exp_denial_rate": 0.88, "ext_review_approved": 7, "std_tat_mean_days": 3.6, "std_tat_median_days": 2, "exp_tat_mean_hours": 33, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.cdphp.com/-/media/files/otherpdfs/interoperabiity-auth-study-medicaid.pdf", "source_segment": "regional", "extraction_note": "TAT units unlabeled; inferred.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0385", "parent_org": "MetroPlus Health Plan", "plan_name": "MetroPlus Medicare (H0423)", "contract_id": "H0423", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 9642, "std_approved": 8482, "std_denied": 1160, "std_denial_rate": 12.03, "std_denial_rate_printed": 12.03, "std_appeals_total": 172, "std_appeals_overturned": 88, "std_appeal_overturn_rate": 51.16, "exp_total": 299, "exp_approved": 219, "exp_denied": 80, "exp_denial_rate": 26.76, "ext_review_approved": 25, "std_tat_mean_days": 2.3, "std_tat_median_days": 0.14, "exp_tat_mean_hours": 34.32, "exp_tat_median_hours": 20.88, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://metroplus.org/wp-content/uploads/2026/07/MEDICARE_HA-851_20260622.xlsx", "source_segment": "w5_metroplus", "extraction_note": "Parsed from MetroPlus's published workbook (the CMS template as an xlsx). Percentages are stored as fractions in the sheet and converted. Both turnaround rows are in days; expedited converted to hours. The workbook the earlier crawl recorded as an unreadable binary gap -- now read.", "source_sha256": "efce0e4d007851e55a1e6984dadfc3ca3168aee8869bd7504da8266601476772", "service_list_url": "https://metroplus.org/members/provider-authorization/", "service_list_items": null, "entity_id": "ma:H0423", "filing_unit": "ma_contract" }, { "filing_id": "f0053", "parent_org": "CDPHP", "plan_name": "CDPHP Medicare HMO", "contract_id": "H3388", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 19167, "std_approved": 16891, "std_denied": 2276, "std_denial_rate": 11.87, "std_denial_rate_printed": null, "std_appeals_total": 270, "std_appeals_overturned": 173, "std_appeal_overturn_rate": 64.07, "exp_total": 1323, "exp_approved": 1284, "exp_denied": 39, "exp_denial_rate": 2.95, "ext_review_approved": 5, "std_tat_mean_days": 3, "std_tat_median_days": 1, "exp_tat_mean_hours": 31, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.cdphp.com/-/media/files/otherpdfs/interoperabiity-auth-study-medicare-hmo.pdf", "source_segment": "regional", "extraction_note": "TAT columns carry no unit labels in this PDF; units inferred from the companion HARP filing.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3388", "filing_unit": "ma_contract" }, { "filing_id": "f0218", "parent_org": "Elevance Health", "plan_name": "Anthem HealthPlus New York Child Health Plus", "contract_id": "G0606", "coverage_type": "CHIP Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 11.6, "std_denial_rate_printed": 11.6, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 42.5, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 9.4, "ext_review_approved": null, "std_tat_mean_days": 3, "std_tat_median_days": 1, "exp_tat_mean_hours": 24, "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.anthembluecross.com/content/dam/digital/docs/anthembluecross/medicaid/new-york/ny_chip_priorauthsmetrics.pdf", "source_segment": "wave2", "extraction_note": "DOES NOT RECONCILE: standard approved 88.8% + denied 11.6% = 100.4%. Re-read in a second pass and confirmed as printed; the error is in the source.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0333", "parent_org": "Independent Health", "plan_name": "Independent Health Medicare H3344", "contract_id": "H3344", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 6688, "std_approved": 5936, "std_denied": 752, "std_denial_rate": 11.24, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 46, "std_appeal_overturn_rate": null, "exp_total": 593, "exp_approved": 523, "exp_denied": 70, "exp_denial_rate": 11.8, "ext_review_approved": 0, "std_tat_mean_days": 2.34, "std_tat_median_days": 0.02, "exp_tat_mean_hours": 10.51, "exp_tat_median_hours": 0.98, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.independenthealth.com/content/dam/independenthealth/individuals-and-families/my-health/prior-authorization-metrics/documents/ih-medicare-h3344.pdf", "source_segment": "regional", "extraction_note": "Appeals reported only as 'approved after appeal' against the ALL-REQUESTS denominator, not appeals filed.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3344", "filing_unit": "ma_contract" }, { "filing_id": "f0262", "parent_org": "Healthfirst", "plan_name": "Contract H9678", "contract_id": "H9678", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": null, "std_total": 11134, "std_approved": 9989, "std_denied": 1145, "std_denial_rate": 10.28, "std_denial_rate_printed": 10, "std_appeals_total": 166, "std_appeals_overturned": 154, "std_appeal_overturn_rate": 92.77, "exp_total": 207, "exp_approved": 175, "exp_denied": 32, "exp_denial_rate": 15.46, "ext_review_approved": 1, "std_tat_mean_days": 1.46, "std_tat_median_days": 0, "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://assets.healthfirst.org/pdf_UYvn9SF1eQX0/2026interoperability-contract-h9678-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "d137ac5b6b8b25c318b49976c9c01269713b4c84d3a267ba355d4bc09ae37b9e", "service_list_url": null, "service_list_items": null, "entity_id": "ma:H9678", "filing_unit": "ma_contract" }, { "filing_id": "f0054", "parent_org": "CDPHP", "plan_name": "CDPHP Medicare PPO", "contract_id": "H5042", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 4069, "std_approved": 3662, "std_denied": 407, "std_denial_rate": 10, "std_denial_rate_printed": null, "std_appeals_total": 69, "std_appeals_overturned": 38, "std_appeal_overturn_rate": 55.07, "exp_total": 279, "exp_approved": 265, "exp_denied": 14, "exp_denial_rate": 5.02, "ext_review_approved": 3, "std_tat_mean_days": 3, "std_tat_median_days": 1, "exp_tat_mean_hours": 29, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.cdphp.com/-/media/files/otherpdfs/interoperabiity-auth-study-medicare-ppo.pdf", "source_segment": "regional", "extraction_note": "TAT units unlabeled; inferred.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5042", "filing_unit": "ma_contract" }, { "filing_id": "f0069", "parent_org": "CVS Health / Aetna", "plan_name": "Aetna Better Health of New York", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "January 1, 2025 - December 31, 2025", "std_total": 53324, "std_approved": 48093, "std_denied": 5321, "std_denial_rate": 9.98, "std_denial_rate_printed": 9.81, "std_appeals_total": 243, "std_appeals_overturned": 6, "std_appeal_overturn_rate": 2.47, "exp_total": 19, "exp_approved": 4, "exp_denied": 15, "exp_denial_rate": 78.95, "ext_review_approved": 0, "std_tat_mean_days": 1.28, "std_tat_median_days": 0, "exp_tat_mean_hours": 4.56, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/newyork/pdf/2025_ABHNY_CMS_Web_Metrics-ProviderMember.pdf", "source_segment": "aetna_ahc", "extraction_note": "Expedited TAT printed in days (0.19 mean / 0 median); converted to hours x24. RECONCILIATION FLAG: printed approved 48,093 + denied 5,321 = 53,414, exceeding the printed standard total of 53,324 by 90. Values transcribed as printed.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:aetna-better-health", "filing_unit": "medicaid_plan" }, { "filing_id": "f0261", "parent_org": "Healthfirst", "plan_name": "Contract H5989", "contract_id": "H5989", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": null, "std_total": 52494, "std_approved": 47266, "std_denied": 5228, "std_denial_rate": 9.96, "std_denial_rate_printed": 10, "std_appeals_total": 507, "std_appeals_overturned": 458, "std_appeal_overturn_rate": 90.34, "exp_total": 674, "exp_approved": 559, "exp_denied": 115, "exp_denial_rate": 17.06, "ext_review_approved": 0, "std_tat_mean_days": 3, "std_tat_median_days": 0.29, "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://assets.healthfirst.org/pdf_dxBhnL8AXbH9/2026interoperability-contract-h5989-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "dcd9c28584992053331b5ef55929d54b4985eb218e582c62aba897f0c0ee7a72", "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5989", "filing_unit": "ma_contract" }, { "filing_id": "f0259", "parent_org": "Healthfirst", "plan_name": "Contract H1722", "contract_id": "H1722", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": null, "std_total": 3316, "std_approved": 2998, "std_denied": 318, "std_denial_rate": 9.59, "std_denial_rate_printed": 10, "std_appeals_total": 49, "std_appeals_overturned": 47, "std_appeal_overturn_rate": 95.92, "exp_total": 71, "exp_approved": 58, "exp_denied": 13, "exp_denial_rate": 18.31, "ext_review_approved": 0, "std_tat_mean_days": 1.69, "std_tat_median_days": 0, "exp_tat_mean_hours": 72, "exp_tat_median_hours": 9, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://assets.healthfirst.org/pdf_fgm9WpwFoBJW/2026interoperability-contract-h1722-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "87c71a67ca2a67dc543346ce91b3ab6e5047ef5b0317e564ff449efa119b33ec", "service_list_url": null, "service_list_items": null, "entity_id": "ma:H1722", "filing_unit": "ma_contract" }, { "filing_id": "f0519", "parent_org": "UnitedHealth Group", "plan_name": "New York Wellness 4Me (HARP)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "CY2025", "std_total": 4461, "std_approved": 4060, "std_denied": 401, "std_denial_rate": 8.99, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 9, "std_appeal_overturn_rate": null, "exp_total": 151, "exp_approved": 148, "exp_denied": 3, "exp_denial_rate": 1.99, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 1.5, "exp_tat_mean_hours": 168, "exp_tat_median_hours": 256.8, "reports_counts": true, "quality_flags": "warn:expedited_slower_than_standard", "error_count": 0, "warn_count": 1, "source_url": "https://www.uhc.com/content/dam/uhcdotcom/en/Legal/PDF/CMS-Interoperability-Medicaid-2025.pdf", "source_segment": "wave2", "extraction_note": "Expedited mean 168h and median 257h are the slowest expedited turnaround in the entire dataset, against a 72-hour standard.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:unitedhealthcare", "filing_unit": "medicaid_plan" }, { "filing_id": "f0334", "parent_org": "Independent Health", "plan_name": "Independent Health Medicare H3362", "contract_id": "H3362", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 117495, "std_approved": 106965, "std_denied": 10530, "std_denial_rate": 8.96, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 534, "std_appeal_overturn_rate": null, "exp_total": 10520, "exp_approved": 9622, "exp_denied": 898, "exp_denial_rate": 8.54, "ext_review_approved": 0, "std_tat_mean_days": 2.05, "std_tat_median_days": 0, "exp_tat_mean_hours": 8.17, "exp_tat_median_hours": 0.21, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.independenthealth.com/content/dam/independenthealth/individuals-and-families/my-health/prior-authorization-metrics/documents/ih-medicare-h3362.pdf", "source_segment": "regional", "extraction_note": "Median standard TAT of 0.0002 days (~17 seconds) implies a large share of auto-approvals.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3362", "filing_unit": "ma_contract" }, { "filing_id": "f0268", "parent_org": "Highmark", "plan_name": "Highmark Medicaid - New York", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "NY", "reporting_period": "Jan 1, 2025 - Dec 31, 2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 8.7, "std_denial_rate_printed": 8.7, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 39.9, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 5.4, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 2, "exp_tat_mean_hours": 24, "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://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. NY row publishes PERCENTAGES ONLY - no counts. Extended review shown as 2.9% approved. Expedited TAT converted from days to hours (mean 1 d = 24 h; median 1 d = 24 h).", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:NY:highmark-western-northeastern-ny", "filing_unit": "medicaid_plan" }, { "filing_id": "f0260", "parent_org": "Healthfirst", "plan_name": "Contract H3359", "contract_id": "H3359", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": null, "std_total": 764446, "std_approved": 701699, "std_denied": 62747, "std_denial_rate": 8.21, "std_denial_rate_printed": 8, "std_appeals_total": 7292, "std_appeals_overturned": 6263, "std_appeal_overturn_rate": 85.89, "exp_total": 6956, "exp_approved": 5911, "exp_denied": 1045, "exp_denial_rate": 15.02, "ext_review_approved": 0, "std_tat_mean_days": 1.54, "std_tat_median_days": 0, "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://assets.healthfirst.org/pdf_ItEdGTWswv1o/2026interoperability-contract-h3359-english", "source_segment": "w5_cms_template", "extraction_note": "parsed from the CMS reporting template by pipeline.preauth.extract (cms)", "source_sha256": "d27f111ef16f59b2199e142eb1ffa7cd2677c24b8cf2df9fb6ddc935c7ec759c", "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3359", "filing_unit": "ma_contract" }, { "filing_id": "f0416", "parent_org": "Molina Healthcare", "plan_name": "Senior Whole Health of New York - Medicare", "contract_id": "H5992", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 8, "std_denial_rate_printed": 8, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 30, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 12, "ext_review_approved": null, "std_tat_mean_days": 2, "std_tat_median_days": 1, "exp_tat_mean_hours": 18, "exp_tat_median_hours": 17, "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/ny/swh/forms/prior-auth-reporting.aspx", "source_segment": "national", "extraction_note": "Percentages only, no counts or denominators.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5992", "filing_unit": "ma_contract" }, { "filing_id": "f0231", "parent_org": "EmblemHealth", "plan_name": "EmblemHealth Medicare H3330", "contract_id": "H3330", "coverage_type": "Medicare Advantage", "state": "NY", "reporting_period": "CY2025", "std_total": 73246, "std_approved": 67575, "std_denied": 5671, "std_denial_rate": 7.74, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 353, "std_appeal_overturn_rate": null, "exp_total": 2958, "exp_approved": 2498, "exp_denied": 460, "exp_denial_rate": 15.55, "ext_review_approved": 51, "std_tat_mean_days": 1.3, "std_tat_median_days": null, "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.emblemhealth.com/providers/clinical-corner/um-and-medical-management/pre-authorization-list/preauthorization-metrics", "source_segment": "regional", "extraction_note": "TURNAROUND UNITS AMBIGUOUS: printed standard mean 1.3 vs median 17.0. Median 13x the mean is implausible in one unit; medians left null rather than inferred.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H3330", "filing_unit": "ma_contract" } ] }