Ambetter of Peach State Inc. (Georgia) in-network claim denial rate: 13.7%

In the CMS Transparency in Coverage file for plan year 2024, Ambetter of Peach State Inc. reported denying 2,410,742 of 17,619,920 in-network claims (13.7%) in Georgia, from 2022 claims. 53.6% of internal appeals were overturned (785 of 1,465). That is the 6th highest reported rate of 9 ranked issuers in Georgia; the state median is 17.7%.

Denial rate

13.7%

2,410,742 of 17,619,920 claims

Appeals overturned

53.6%

785 of 1,465 filed

External review overturned

100.0%

not reported

Compared with Georgia and the national median

Measure	Ambetter of Peach State Inc.	Georgia median	National median
In-network denial rate	13.7%	17.7%	15.5%
In-network claims received	17,619,920	—	—
Internal appeals filed	1,465	—	—
Internal appeal overturn rate	53.6%	45.3%	45.9%
External reviews filed	n/a	—	—
External review overturn rate	100.0%	100.0%	64.1%
Out-of-network denial rate	43.3%	—	—

Medians are across issuers with at least 1,000 in-network claims received in the same file (Georgia: 9 issuers; national: 174 issuers in 32 states). Plan year 2024 file, 2022 claims.

Read these numbers carefully

Reporting lag: the CMS public-use file for a plan year reports claims from two plan years earlier (the PY2025 file carries 2023 claims). These are not this year's figures.
In-network only: the denial rate is in-network claims denied divided by in-network claims received. Out-of-network claims are shown separately where the issuer reported them.
"Denied" is broad: CMS counts every denial, including administrative denials, duplicate submissions, ineligibility, incorrect billing and partial denials, not only medical-necessity decisions.
Issuer level: CMS reports the counts once per issuer per state and repeats them on every plan row; plan-level counts, where present, list denials only, so no per-plan rate is computed.
Coverage: only issuers on the federally facilitated marketplace (HealthCare.gov states) report to this file. Employer plans, Medicare and Medicaid are not included.
No inference of intent: a higher rate can reflect the issuer's mix of claims, its billing rules or its membership as much as its coverage decisions. Compare with the state median and read the N.

Source: CMS Transparency in Coverage Public Use File (Health Insurance Exchange PUFs), plan year 2024; data dictionary. Issuer's own claims-payment policy page: https://ambetter.pshpgeorgia.com/resources/handbooks-forms/transparency-notice-2024.html.

If Ambetter of Peach State Inc. denied your claim

A denial is a decision you can contest. Marketplace plans must give you at least 180 days to file an internal appeal and offer independent external review after it (45 CFR 147.136). The letter states your deadline.

Plans in this filing (32)

Where CMS lists plan-level denial counts they are shown; no plan-level rate is computed because the file does not give plan-level claims received.

Plan ID	Type	Metal	Plan-level denials (in-network)
70893GA0010006	HMO	Bronze	72,153
70893GA0010017	HMO	Silver	343,099
70893GA0010020	HMO	Gold	117,004
70893GA0010051	HMO	Bronze Expanded	36,543
70893GA0010064	HMO	Bronze Expanded	55,298
70893GA0010068	HMO	Silver	164,182
70893GA0010070	HMO	Silver	574,191
70893GA0010071	HMO	Gold	48,738
70893GA0010073	HMO	Gold	n/a
70893GA0010074	HMO	Gold	n/a
70893GA0010076	HMO	Bronze Expanded	n/a
70893GA0010077	HMO	Silver	n/a
70893GA0010078	HMO	Gold	n/a
70893GA0030017	HMO	Silver	61,281
70893GA0030019	HMO	Bronze	25,469
70893GA0030020	HMO	Gold	52,589
70893GA0030051	HMO	Bronze Expanded	12,133
70893GA0030064	HMO	Bronze Expanded	7,230
70893GA0030070	HMO	Silver	115,938
70893GA0030071	HMO	Gold	15,837
70893GA0030072	HMO	Silver	n/a
70893GA0030074	HMO	Gold	n/a
70893GA0030075	HMO	Gold	n/a
70893GA0030076	HMO	Bronze Expanded	n/a
70893GA0030077	HMO	Silver	n/a
70893GA0030078	HMO	Gold	n/a
70893GA0060013	HMO	Silver	n/a
70893GA0060014	HMO	Gold	n/a
70893GA0070013	HMO	Silver	n/a
70893GA0070014	HMO	Gold	n/a
70893GA0090007	HMO	Silver	n/a
70893GA0090008	HMO	Gold	n/a

Questions

What counts as a "denied" claim in Ambetter of Peach State Inc.'s 13.7% rate?

Every in-network claim the issuer reported as denied in the 2022 claims year, including administrative denials, duplicates, ineligibility, incorrect billing and partial denials, not only medical-necessity decisions. The figure is in-network claims denied divided by in-network claims received, exactly as reported to CMS.

Why is the data from 2022 when the file is for plan year 2024?

CMS's Transparency in Coverage public use file for a plan year reports claims data from two plan years earlier. This is the most recent issuer-level denial data CMS publishes for marketplace plans.

Does this predict whether my Ambetter of Peach State Inc. claim will be denied?

No. It is an aggregate across all of the issuer's marketplace plans in Georgia. Your own claim depends on your plan, the service and the documentation. Compare the rate with the Georgia median (17.7%) and read the N before drawing conclusions.

How do I appeal a Ambetter of Peach State Inc. denial?

Read the denial letter for the reason and the deadline, request the criteria and the claim file in writing, and file an internal appeal (at least 180 days on marketplace plans under 45 CFR 147.136). In the reporting year, 53.6% of internal appeals to this issuer were overturned (785 of 1,465). If the internal appeal fails, independent external review is available.

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Cite: Apellica Insurer Denial Report Cards, Ambetter of Peach State Inc. (Georgia), plan year 2024, from the CMS Transparency in Coverage PUF. CC BY 4.0. Download the full table as CSV or read the methodology. Corrections: editorial@apellica.com.