What is my health insurer's claim denial rate?
If your plan was bought on HealthCare.gov, your insurer reports its in-network claims received, denied, appealed and overturned to CMS every year, and Apellica publishes every issuer's numbers by state with the N. Median issuers deny roughly one in five in-network claims, and the figure includes administrative denials, so read it against the state median rather than on its own.
What to do, in order
- Step 1
Find your issuer and state
Open the report cards, pick your state, and find the issuer name printed on your card. The page shows claims received, claims denied, the rate, appeals filed and the share overturned, exactly as reported.
- Step 2
Compare with the state median
A rate above the state median is worth knowing; a rate below it does not mean your claim is safe. The counts include duplicate and administrative denials, so the mix of claims matters.
- Step 3
Look at the appeal overturn rate
It tells you how often this issuer reverses itself when a member pushes back. Most denials are never appealed at all.
- Step 4
If you were denied, appeal
Request the criteria and the claim file, file the internal appeal within the deadline on your letter, and use external review if it is upheld.
The deadline that applies
The report cards are data, not a deadline. If you hold a denial letter, the appeal clock on that letter controls: at least 180 days to file an internal appeal on marketplace plans (45 CFR 147.136).
Calculate your date →Documents to gather
- Your insurance card (issuer name and state)
- The denial letter, if you have one
Go deeper
Related questions
Why is the data two years old?
CMS's Transparency in Coverage public use file for a plan year reports claims from two plan years earlier. It is the most recent issuer-level denial data CMS publishes for marketplace plans.
My insurer is not listed. Why?
Only issuers selling on HealthCare.gov report to this file. State-run marketplaces, employer plans, Medicare and Medicaid are not included.
Does a high denial rate mean the insurer is acting in bad faith?
No. The rate reflects the issuer's claim mix, billing rules and membership as much as its coverage decisions. Apellica publishes the numbers with their N and does not infer intent.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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