Avera Health Plans, Inc. (South Dakota) in-network claim denial rate: 1.5%
In the CMS Transparency in Coverage file for plan year 2025, Avera Health Plans, Inc. reported denying 6,325 of 433,953 in-network claims (1.5%) in South Dakota, from 2023 claims. 54.7% of internal appeals were overturned (122 of 223). That is the 3rd highest reported rate of 3 ranked issuers in South Dakota; the state median is 5.0%.
Prior file (plan year 2024, 2022 claims): denial rate 3.1% (13,424 of 432,992); appeal overturn rate 39.2%.
Compared with South Dakota and the national median
| Measure | Avera Health Plans, Inc. | South Dakota median | National median |
|---|---|---|---|
| In-network denial rate | 1.5% | 5.0% | 18.3% |
| In-network claims received | 433,953 | — | — |
| Internal appeals filed | 223 | — | — |
| Internal appeal overturn rate | 54.7% | 54.7% | 41.7% |
| External reviews filed | n/a | — | — |
| External review overturn rate | n/a | n/a | 0.0% |
| Out-of-network denial rate | 71.9% | — | — |
Medians are across issuers with at least 1,000 in-network claims received in the same file (South Dakota: 3 issuers; national: 176 issuers in 32 states). Plan year 2025 file, 2023 claims.
- 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.averahealthplans.com/insurance/about/legal-privacy-notices/transparency-in-coverage/.
If Avera Health Plans, 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 (29)
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) |
|---|---|---|---|
| 60536SD0020007 | PPO | Gold | 94 |
| 60536SD0020018 | PPO | Catastrophic | 12 |
| 60536SD0020022 | PPO | Silver | 760 |
| 60536SD0020023 | PPO | Bronze | 581 |
| 60536SD0020024 | PPO | Bronze | 466 |
| 60536SD0020039 | PPO | Silver | 587 |
| 60536SD0020041 | PPO | Gold | n/a |
| 60536SD0020043 | PPO | Silver | 37 |
| 60536SD0020045 | PPO | Silver | 55 |
| 60536SD0020046 | PPO | Bronze | 248 |
| 60536SD0020047 | PPO | Bronze | 118 |
| 60536SD0020050 | PPO | Catastrophic | n/a |
| 60536SD0020051 | PPO | Gold | 21 |
| 60536SD0020052 | PPO | Silver | 1,122 |
| 60536SD0020057 | PPO | Gold | 15 |
| 60536SD0020058 | PPO | Silver | 119 |
| 60536SD0020064 | PPO | Gold | n/a |
| 60536SD0020065 | PPO | Gold | n/a |
| 60536SD0020066 | PPO | Bronze | n/a |
| 60536SD0020067 | PPO | Bronze | n/a |
| 60536SD0060013 | HMO | Silver | 333 |
| 60536SD0060014 | HMO | Bronze | 217 |
| 60536SD0060015 | HMO | Bronze | 91 |
| 60536SD0060017 | HMO | Gold | 14 |
| 60536SD0060018 | HMO | Silver | 361 |
| 60536SD0060021 | HMO | Bronze | n/a |
| 60536SD0060022 | HMO | Gold | n/a |
| 60536SD0060027 | HMO | Gold | n/a |
| 60536SD0060028 | HMO | Silver | n/a |
Questions
What counts as a "denied" claim in Avera Health Plans, Inc.'s 1.5% 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 Avera Health Plans, Inc. claim will be denied?
No. It is an aggregate across all of the issuer's marketplace plans in South Dakota. Your own claim depends on your plan, the service and the documentation. Compare the rate with the South Dakota median (5.0%) and read the N before drawing conclusions.
How do I appeal a Avera Health Plans, 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, 54.7% of internal appeals to this issuer were overturned (122 of 223). If the internal appeal fails, independent external review is available.
Cite: Apellica Insurer Denial Report Cards, Avera Health Plans, Inc. (South Dakota), 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.