Oregon health insurers by reported claim denial rate
6 marketplace issuers in Oregon reported 277,498 denials on 2,552,164 in-network claims from 2024 (pooled rate 10.9%). The median rate among the 6 ranked issuers is 10.2%, against a national median of 19.0% across 32 HealthCare.gov states. Of 1,265 internal appeals filed, 31.7% were overturned.
All issuers reporting in Oregon, plan year 2026 file
| # | Issuer | Claims received | Denied | Denial rate | Appeals filed | Overturned |
|---|---|---|---|---|---|---|
| 1 | PacificSource Health Plans | 3,771 | 658 | 17.4% | 136 | 8.8% |
| 2 | Moda Health Plan, Inc. | 1,102,738 | 157,741 | 14.3% | 173 | 38.7% |
| 3 | BridgeSpan Health Company | 12,346 | 1,294 | 10.5% | n/a | n/a |
| 4 | Regence BlueCross BlueShield of Oregon | 1,013,376 | 100,498 | 9.9% | 616 | 14.3% |
| 5 | Kaiser Foundation Healthplan of the NW | 9,923 | 725 | 7.3% | 39 | 43.6% |
| 6 | Providence Health Plan | 410,010 | 16,582 | 4.0% | 301 | 72.1% |
Sorted by reported in-network denial rate. Rank is shown only for issuers with at least 1,000 in-network claims received; smaller issuers are listed without a rank. Source: CMS Transparency in Coverage PUF.
- Reporting lag: the CMS public-use file for a plan year reports claims from two plan years earlier (the PY2026 file carries 2024 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) · data dictionary.
Denied in Oregon? What to do
- Oregon appeal rights and regulator →
- Oregon external-review reversal rate →
- Appeal deadline calculator →
- Have Apellica prepare the appeal ($0 upfront) →
Questions
Which Oregon marketplace insurer reported the highest claim denial rate?
Among issuers with at least 1,000 in-network claims, PacificSource Health Plans reported the highest rate in the plan year 2026 file: 17.4% (658 of 3,771 claims from 2024). The Oregon median is 10.2%. A high rate can reflect claim mix and billing rules as much as coverage decisions.
Does a lower denial rate mean a better plan?
Not by itself. Rates include administrative denials and depend on the issuer's membership and claim mix. Use the rate alongside network, premium, formulary and the appeal overturn rate, and read the caveats.
Where does this data come from?
The CMS Transparency in Coverage public use file for plan year 2026, which reports each issuer's 2024 in-network claims received and denied, internal appeals and external reviews for plans sold on HealthCare.gov. Apellica removed stand-alone dental issuers and computed nothing beyond the reported counts.
How do I appeal a denial in Oregon?
File an internal appeal within the deadline on your letter (at least 180 days on marketplace plans), request the plan's criteria and claim file in writing, then use Oregon's external review if the plan upholds the denial. The regulator is Oregon Division of Financial Regulation.
Download the full table as CSV · methodology · CC BY 4.0.