Medica Insurance Company (Oklahoma) in-network claim denial rate: 23.9%

In the CMS Transparency in Coverage file for plan year 2025, Medica Insurance Company reported denying 85,961 of 359,100 in-network claims (23.9%) in Oklahoma, from 2023 claims. 50.8% of internal appeals were overturned (66 of 130). That is the 2nd highest reported rate of 6 ranked issuers in Oklahoma; the state median is 22.5%.

Denial rate

23.9%

85,961 of 359,100 claims

Appeals overturned

50.8%

66 of 130 filed

External review overturned

n/a

not reported

Prior file (plan year 2024, 2022 claims): denial rate 22.0% (87,492 of 397,303); appeal overturn rate 41.3%.

Compared with Oklahoma and the national median

Measure	Medica Insurance Company	Oklahoma median	National median
In-network denial rate	23.9%	22.5%	18.3%
In-network claims received	359,100	—	—
Internal appeals filed	130	—	—
Internal appeal overturn rate	50.8%	37.0%	41.7%
External reviews filed	n/a	—	—
External review overturn rate	n/a	0.0%	0.0%
Out-of-network denial rate	49.6%	—	—

Medians are across issuers with at least 1,000 in-network claims received in the same file (Oklahoma: 6 issuers; national: 176 issuers in 32 states). Plan year 2025 file, 2023 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 2025; data dictionary. Issuer's own claims-payment policy page: https://www.medica.com/transparency-in-coverage.

If Medica Insurance Company 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 (30)

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)
21333OK0010013	PPO	Catastrophic	156
21333OK0010041	PPO	Bronze	13,265
21333OK0010045	PPO	Gold	5,709
21333OK0010047	PPO	Silver	n/a
21333OK0010051	PPO	Bronze	6,778
21333OK0010055	PPO	Gold	2,052
21333OK0010057	PPO	Silver	28,116
21333OK0010073	PPO	Bronze	n/a
21333OK0010074	PPO	Gold	n/a
21333OK0010075	PPO	Silver	n/a
21333OK0060013	PPO	Catastrophic	64
21333OK0060045	PPO	Gold	2,189
21333OK0060047	PPO	Silver	n/a
21333OK0060051	PPO	Bronze	3,102
21333OK0060055	PPO	Gold	798
21333OK0060057	PPO	Silver	7,532
21333OK0060073	PPO	Bronze	n/a
21333OK0060074	PPO	Bronze	n/a
21333OK0060075	PPO	Gold	n/a
21333OK0060076	PPO	Silver	n/a
21333OK0070001	PPO	Gold	n/a
21333OK0070002	PPO	Silver	n/a
21333OK0070003	PPO	Bronze	n/a
21333OK0070004	PPO	Gold	n/a
21333OK0070005	PPO	Silver	n/a
21333OK0070006	PPO	Bronze	n/a
21333OK0070007	PPO	Gold	n/a
21333OK0070008	PPO	Silver	n/a
21333OK0070009	PPO	Bronze	n/a
21333OK0070010	PPO	Catastrophic	n/a

Questions

What counts as a "denied" claim in Medica Insurance Company's 23.9% rate?

Every in-network claim the issuer reported as denied in the 2023 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 2023 when the file is for plan year 2025?

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 Medica Insurance Company claim will be denied?

No. It is an aggregate across all of the issuer's marketplace plans in Oklahoma. Your own claim depends on your plan, the service and the documentation. Compare the rate with the Oklahoma median (22.5%) and read the N before drawing conclusions.

How do I appeal a Medica Insurance Company 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, 50.8% of internal appeals to this issuer were overturned (66 of 130). If the internal appeal fails, independent external review is available.

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Cite: Apellica Insurer Denial Report Cards, Medica Insurance Company (Oklahoma), plan year 2025, 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.