{ "meta": { "total": 15, "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": "f0419", "parent_org": "Network Health (Wisconsin)", "plan_name": "Network Health MSA Network Prime", "contract_id": "H1181", "coverage_type": "Medicare Advantage", "state": "WI", "reporting_period": "CY2025", "std_total": 790, "std_approved": 652, "std_denied": 138, "std_denial_rate": 17.47, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 0, "std_appeal_overturn_rate": null, "exp_total": 34, "exp_approved": 32, "exp_denied": 2, "exp_denial_rate": 5.88, "ext_review_approved": 0, "std_tat_mean_days": 3, "std_tat_median_days": 2, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 24, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://networkhealth.com/__assets/pdf/provider-resources/prior-authorization-metrics-reporting-overview-template_h1181.pdf", "source_segment": "regional", "extraction_note": "INTERNAL CONTRADICTION: document states 'this plan does not have any prior authorization requirements' yet reports 790 standard and 34 expedited requests.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H1181", "filing_unit": "ma_contract" }, { "filing_id": "f0328", "parent_org": "Humana / iCare", "plan_name": "iCare BadgerCare Plus", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025", "std_total": 8424, "std_approved": 7159, "std_denied": 1265, "std_denial_rate": 15.02, "std_denial_rate_printed": null, "std_appeals_total": 33, "std_appeals_overturned": 7, "std_appeal_overturn_rate": 21.21, "exp_total": 266, "exp_approved": 187, "exp_denied": 79, "exp_denial_rate": 29.7, "ext_review_approved": 87, "std_tat_mean_days": 4, "std_tat_median_days": 1, "exp_tat_mean_hours": 17, "exp_tat_median_hours": 9, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.humana.com/is/content/humana/iCare_BadgerCarePlus_Prior_Auth_Metrics_PlanYear2025pdf", "source_segment": "wave2", "extraction_note": "Appeals reported as a single combined standard+expedited figure.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:WI:independent-care-health-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0161", "parent_org": "Centene", "plan_name": "MHS Health Wisconsin (NHP line)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025", "std_total": 11224, "std_approved": 9542, "std_denied": 1682, "std_denial_rate": 14.99, "std_denial_rate_printed": null, "std_appeals_total": 41, "std_appeals_overturned": 10, "std_appeal_overturn_rate": 24.39, "exp_total": 225, "exp_approved": 200, "exp_denied": 25, "exp_denial_rate": 11.11, "ext_review_approved": 0, "std_tat_mean_days": 4, "std_tat_median_days": 3, "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.mhswi.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/WI_MHSHealthWI_Medicaid_NHP_MetricsSummary_R.pdf", "source_segment": "wave2", "extraction_note": "Line of business labeled 'WI-NHP'; expansion not stated in the document.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:WI:mhs-health-wisconsin", "filing_unit": "medicaid_plan" }, { "filing_id": "f0418", "parent_org": "Network Health (Wisconsin)", "plan_name": "Network Health ACA/exchange plans", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "WI", "reporting_period": "CY2025", "std_total": 11043, "std_approved": 9509, "std_denied": 1534, "std_denial_rate": 13.89, "std_denial_rate_printed": null, "std_appeals_total": 17, "std_appeals_overturned": 10, "std_appeal_overturn_rate": 58.82, "exp_total": 415, "exp_approved": 316, "exp_denied": 99, "exp_denial_rate": 23.86, "ext_review_approved": 0, "std_tat_mean_days": 4, "std_tat_median_days": 1.5, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 36, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://networkhealth.com/__assets/pdf/provider-resources/prior-authorization-metrics-reporting-overview-template_aca.pdf", "source_segment": "regional", "extraction_note": "Expedited denial rate (24%) is roughly double the standard rate, the reverse of the usual pattern.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0255", "parent_org": "HealthPartners", "plan_name": "HealthPartners Commercial Wisconsin Federally Facilitated Exchange (on-exchange QHP) plans", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "WI", "reporting_period": "CY2025 (January 1, 2025 - December 31, 2025)", "std_total": 1172, "std_approved": 1011, "std_denied": 161, "std_denial_rate": 13.74, "std_denial_rate_printed": 14, "std_appeals_total": 19, "std_appeals_overturned": 16, "std_appeal_overturn_rate": 84.21, "exp_total": 108, "exp_approved": 92, "exp_denied": 16, "exp_denial_rate": 14.81, "ext_review_approved": null, "std_tat_mean_days": 4, "std_tat_median_days": 0, "exp_tat_mean_hours": 21.68, "exp_tat_median_hours": 0.72, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://www.healthpartners.com/content/dam/corporate/integrity-compliance/pa-reporting-cy2025-ma-medadv-msho-indwionexch.pdf", "source_segment": "w3_midwest", "extraction_note": "Document labels this line 'QHP issuers on the FFEs (HealthPartners Commercial WI Federally Facilitated Exchange Products)'. Expedited appeals reported separately (1 total, 0 overturned) but no exp_appeals field exists in this schema; noted here only.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "qhp:WI:20173", "filing_unit": "qhp_issuer" }, { "filing_id": "f0330", "parent_org": "Humana / iCare", "plan_name": "iCare Medicaid SSI", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025", "std_total": 6385, "std_approved": 5537, "std_denied": 848, "std_denial_rate": 13.28, "std_denial_rate_printed": null, "std_appeals_total": 41, "std_appeals_overturned": 8, "std_appeal_overturn_rate": 19.51, "exp_total": 231, "exp_approved": 188, "exp_denied": 43, "exp_denial_rate": 18.61, "ext_review_approved": 388, "std_tat_mean_days": 6, "std_tat_median_days": 5, "exp_tat_mean_hours": 22, "exp_tat_median_hours": 12, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.humana.com/is/content/humana/iCare_SSIMedicaid_Prior_Auth_Metrics_PlanYear2025pdf", "source_segment": "wave2", "extraction_note": "Appeals reported combined, not split.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:WI:independent-care-health-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0420", "parent_org": "Network Health (Wisconsin)", "plan_name": "Network Health Medicare Advantage", "contract_id": "H5215", "coverage_type": "Medicare Advantage", "state": "WI", "reporting_period": "CY2025", "std_total": 122707, "std_approved": 107708, "std_denied": 14999, "std_denial_rate": 12.22, "std_denial_rate_printed": null, "std_appeals_total": 501, "std_appeals_overturned": 321, "std_appeal_overturn_rate": 64.07, "exp_total": 2257, "exp_approved": 1938, "exp_denied": 319, "exp_denial_rate": 14.13, "ext_review_approved": 0, "std_tat_mean_days": 3, "std_tat_median_days": 2, "exp_tat_mean_hours": 48, "exp_tat_median_hours": 48, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://networkhealth.com/__assets/pdf/provider-resources/prior-authorization-metrics-reporting-overview-template_h5215.pdf", "source_segment": "regional", "extraction_note": "Contract ID taken from filename, not printed inside the PDF. Expedited TAT published in days, x24.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H5215", "filing_unit": "ma_contract" }, { "filing_id": "f0329", "parent_org": "Humana / iCare", "plan_name": "iCare Family Care Partnership", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025", "std_total": 2717, "std_approved": 2409, "std_denied": 308, "std_denial_rate": 11.34, "std_denial_rate_printed": null, "std_appeals_total": 5, "std_appeals_overturned": 2, "std_appeal_overturn_rate": 40, "exp_total": 217, "exp_approved": 192, "exp_denied": 25, "exp_denial_rate": 11.52, "ext_review_approved": 40, "std_tat_mean_days": 4, "std_tat_median_days": 3, "exp_tat_mean_hours": 14, "exp_tat_median_hours": 3, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.humana.com/is/content/humana/iCare_FamilyCarePartnership_Prior_Auth_Metrics_PlanYear2025pdf", "source_segment": "wave2", "extraction_note": "Integrated LTSS product published under the Medicaid section.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:WI:independent-care-health-plan", "filing_unit": "medicaid_plan" }, { "filing_id": "f0410", "parent_org": "Molina Healthcare", "plan_name": "Molina Healthcare of Wisconsin - BadgerCare Plus", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 10, "std_denial_rate_printed": 10, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 63, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 9, "ext_review_approved": null, "std_tat_mean_days": 5, "std_tat_median_days": 4, "exp_tat_mean_hours": 25, "exp_tat_median_hours": 22, "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/wi/medicaid/forms/fuf.aspx", "source_segment": "w3_gaps_a", "extraction_note": "Companion table to 'Molina Healthcare of Wisconsin - Medicaid SSI' on the same page, titled 'Medicaid BadgerCare Plus Prior Authorization Annual Report 2025'. Percentages only. Figures with no corresponding schema field: expedited-request appeal overturn 67%; extended-timeframe requests approved 80% (standard) / 89% (expedited). Same verification caveat applies.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:WI:molina-healthcare-of-wisconsin", "filing_unit": "medicaid_plan" }, { "filing_id": "f0331", "parent_org": "Humana / iCare", "plan_name": "iCare Medicare Plan", "contract_id": "H2237", "coverage_type": "Medicare Advantage", "state": "WI", "reporting_period": "CY2025", "std_total": 4424, "std_approved": 3997, "std_denied": 427, "std_denial_rate": 9.65, "std_denial_rate_printed": null, "std_appeals_total": 12, "std_appeals_overturned": 4, "std_appeal_overturn_rate": 33.33, "exp_total": 32, "exp_approved": 24, "exp_denied": 8, "exp_denial_rate": 25, "ext_review_approved": 90, "std_tat_mean_days": 5, "std_tat_median_days": 5, "exp_tat_mean_hours": 7, "exp_tat_median_hours": 0, "reports_counts": true, "quality_flags": "clean", "error_count": 0, "warn_count": 0, "source_url": "https://assets.humana.com/is/content/humana/iCare_H2237_Prior_Auth_Metrics_PlanYear2025pdf", "source_segment": "wave2", "extraction_note": "The only Humana-affiliated filing located in the entire project.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ma:H2237", "filing_unit": "ma_contract" }, { "filing_id": "f0602", "parent_org": "UnitedHealth Group", "plan_name": "Wisconsin Medicaid", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025", "std_total": 80913, "std_approved": 74642, "std_denied": 6271, "std_denial_rate": 7.75, "std_denial_rate_printed": null, "std_appeals_total": null, "std_appeals_overturned": 183, "std_appeal_overturn_rate": null, "exp_total": 7784, "exp_approved": 7525, "exp_denied": 259, "exp_denial_rate": 3.33, "ext_review_approved": null, "std_tat_mean_days": 0, "std_tat_median_days": 0.9, "exp_tat_mean_hours": 0, "exp_tat_median_hours": 16.8, "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:WI:mhs-health-wisconsin", "filing_unit": "medicaid_plan" }, { "filing_id": "f0411", "parent_org": "Molina Healthcare", "plan_name": "Molina Healthcare of Wisconsin - Medicaid SSI", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 7, "std_denial_rate_printed": 7, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": 57, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 8, "ext_review_approved": null, "std_tat_mean_days": 6, "std_tat_median_days": 4, "exp_tat_mean_hours": 29, "exp_tat_median_hours": 23, "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/wi/medicaid/forms/fuf.aspx", "source_segment": "w3_gaps_a", "extraction_note": "Page carries two separate CMS-0057 tables for Wisconsin — this one titled 'Medicaid SSI Prior Authorization Annual Report 2025'; see the companion 'Molina Healthcare of Wisconsin - BadgerCare Plus' filing in this file for the other. Percentages only. Figures with no corresponding schema field: expedited-request appeal overturn 100%; extended-timeframe requests approved 92% (standard) / 78% (expedited). Same verification caveat as the other Molina filings in this file applies.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:WI:molina-healthcare-of-wisconsin", "filing_unit": "medicaid_plan" }, { "filing_id": "f0654", "parent_org": "Wisconsin Department of Health Services", "plan_name": "Wisconsin Medicaid (ForwardHealth) -- specific program/agency not named in document", "contract_id": null, "coverage_type": "Medicaid FFS", "state": "WI", "reporting_period": "Reporting Year 2025", "std_total": 165012, "std_approved": 148796, "std_denied": 6556, "std_denial_rate": 3.97, "std_denial_rate_printed": 4, "std_appeals_total": null, "std_appeals_overturned": null, "std_appeal_overturn_rate": null, "exp_total": 10, "exp_approved": 9, "exp_denied": 0, "exp_denial_rate": 0, "ext_review_approved": null, "std_tat_mean_days": 3.1, "std_tat_median_days": 1, "exp_tat_mean_hours": 151.2, "exp_tat_median_hours": 67.2, "reports_counts": true, "quality_flags": "error:std_counts_reconcile; info:appeals_not_reported; warn:expedited_slower_than_standard", "error_count": 1, "warn_count": 1, "source_url": "https://www.dhs.wisconsin.gov/medicaid/pa-report-2025.pdf", "source_segment": "w3_midwest", "extraction_note": "Document title is only 'Prior Authorization Metrics Reporting Year 2025' -- it names no specific plan, MCO, or program (no BadgerCare Plus / ForwardHealth / managed-care label appears). Hosted on the WI DHS Medicaid pages alongside ForwardHealth FFS pharmacy/PA administrative-code material, so classified here as Medicaid FFS, but this could instead be a statewide combined FFS+MCO carve-in PA determination log -- flag for verification by someone who can see the full PDF. Document also reports a separate 'Partially Denied' bucket not in this schema: standard 9,660 (5.9%%), expedited 1 -- omitted from typed fields, noted here. Standard TAT is explicitly labeled in days (3.1 mean / 1.0 median). Expedited TAT is ALSO explicitly labeled in days (6.3 mean / 2.8 median) rather than hours; converted per brief instructions (days->hours: 6.3*24=151.2, 2.8*24=67.2) and flagged as a conversion. Note the apparent anomaly that expedited turnaround (151.2h / 67.2h) is far slower than standard (3.1 days = 74.4h / 1.0 day = 24h) -- printed as-is; worth scrutiny downstream. No appeals data reported.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "ffs:WI", "filing_unit": "ffs_state" }, { "filing_id": "f0244", "parent_org": "Group Health Cooperative of South Central Wisconsin", "plan_name": "GHC-SCW Qualified Health Plan (Marketplace)", "contract_id": null, "coverage_type": "Marketplace QHP", "state": "WI", "reporting_period": "CY2025 (Jan 1 - Dec 31, 2025)", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 3, "std_denial_rate_printed": 3, "std_appeals_total": 4, "std_appeals_overturned": null, "std_appeal_overturn_rate": 25, "exp_total": null, "exp_approved": null, "exp_denied": null, "exp_denial_rate": 3, "ext_review_approved": null, "std_tat_mean_days": 1, "std_tat_median_days": 0, "exp_tat_mean_hours": 4.8, "exp_tat_median_hours": 0, "reports_counts": false, "quality_flags": "info:percentages_only", "error_count": 0, "warn_count": 0, "source_url": "https://ghcscw.com/wp-content/uploads/2026/02/MK26-9-02.26FL_Prior-Authorization-Summary-Flier_2025_V1.pdf", "source_segment": "w3_midwest", "extraction_note": "Percentages only (97%/3% standard, 97%/3% urgent) -- reports_counts=false, no counts recorded. Document prints a footnote that only 4 appeals total occurred in this line ('*Only had 4 appeals in these categories') with 25% approved / 75% denied after appeal -- recorded std_appeals_total=4 and std_appeal_overturn_pct=25 as printed; did NOT compute the corresponding overturned headcount (would require multiplying 25%x4, which is a derived number, not a transcribed one). Document explicitly labels expedited/urgent TAT in days (0.2 mean / 0 median); converted to hours per brief instructions (0.2*24=4.8, 0*24=0) and flagged as a conversion.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": null, "filing_unit": null }, { "filing_id": "f0243", "parent_org": "Group Health Cooperative of South Central Wisconsin", "plan_name": "GHC-SCW BadgerCare Plus (WI Medicaid)", "contract_id": null, "coverage_type": "Medicaid Managed Care", "state": "WI", "reporting_period": "CY2025 (Jan 1 - Dec 31, 2025)", "std_total": null, "std_approved": null, "std_denied": null, "std_denial_rate": 2, "std_denial_rate_printed": 2, "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": 1, "ext_review_approved": null, "std_tat_mean_days": 1.2, "std_tat_median_days": 0, "exp_tat_mean_hours": 9.6, "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://ghcscw.com/wp-content/uploads/2026/02/MK26-9-02.26FL_Prior-Authorization-Summary-Flier_2025_V1.pdf", "source_segment": "w3_midwest", "extraction_note": "This filing (and the Marketplace QHP line below, from the same document) publishes only rounded approval/denial percentages (98%/2% standard, 99%/1% urgent) with no underlying counts -- reports_counts=false, no std_total/std_approved/std_denied recorded per the NULL-is-not-zero rule. Document explicitly labels expedited/urgent TAT in days (0.4 mean / 0 median), not hours -- converted per brief instructions (0.4*24=9.6, 0*24=0) and flagged as a conversion. No appeals data reported for this line.", "source_sha256": null, "service_list_url": null, "service_list_items": null, "entity_id": "mcd:WI:group-health-cooperative-of-south-central-wi", "filing_unit": "medicaid_plan" } ] }