# Apellica Insurer Denial Report Cards: Methodology

Version 1.0, generated 2026-09-11. Creative Commons Attribution 4.0 International (CC-BY-4.0) (https://creativecommons.org/licenses/by/4.0/). Canonical: https://apellica.com/insurer-denial-rates. Corrections: editorial@apellica.com.

## Source
CMS Transparency in Coverage Public Use File (Health Insurance Exchange PUFs). Dataset page: https://data.healthcare.gov/dataset/230fcdc8-3a0b-48d5-98d9-36744a87906e. Data dictionary: https://www.cms.gov/files/document/transparency-coverage-puf-datadictionary-py25.pdf. Index of Exchange PUFs: https://www.cms.gov/marketplace/resources/data/public-use-files.

Plan years in this release: 2024, 2025. Each plan-year file reports claims from two plan years earlier: PY2024 file = 2022 claims; PY2025 file = 2023 claims.

## What was done
1. Parsed 10,459 plan-level rows from the PUF (individual-market QHPs and stand-alone dental plans on HealthCare.gov, 32 states).
2. Removed 1,168 stand-alone dental rows (metal level "Low" or "High").
3. Collapsed the remaining rows to one record per issuer, state and plan year (194 issuer-state pairs), because CMS reports claims, appeals and external-review counts at the issuer level and repeats them on every plan row.
4. Computed in-network denial rate = in-network claims denied / in-network claims received; internal appeal overturn rate = appeals overturned / appeals filed; external review overturn rate = external reviews overturned / external reviews filed. Where the file supplied both a percentage and the counts, the counts were used.
5. Computed state and national medians across issuers with at least 1,000 in-network claims received (the ranking threshold) and pooled rates as total denied / total received. Issuers below the threshold are listed but not ranked.
6. Nothing was estimated, imputed or adjusted. Issuer names are as printed in the file.

## Headline figures (PY2025 file, 2023 claims)
- Issuer-state filings: 178 (176 ranked)
- Pooled in-network denial rate: 19.7% (85,897,790 of 436,012,342)
- Median issuer denial rate: 18.3%
- Internal appeals filed: 376,704; overturned: 43.8% (median issuer 41.7%)

## Caveats (shown verbatim on every page)
- 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.

## Citation
Apellica (2026). Insurer Denial Report Cards: in-network claim denial and appeal overturn rates reported by marketplace issuers to CMS, plan years 2024 and 2025. v1.0, generated 2026-09-11. Derived from the CMS Transparency in Coverage PUF. CC-BY-4.0. https://apellica.com/insurer-denial-rates