Avera Health Plans, Inc. (South Dakota) in-network claim denial rate: 2.7%

In the CMS Transparency in Coverage file for plan year 2026, Avera Health Plans, Inc. reported denying 11,752 of 436,009 in-network claims (2.7%) in South Dakota, from 2024 claims. 44.8% of internal appeals were overturned (69 of 154). That is the 3rd highest reported rate of 3 ranked issuers in South Dakota; the state median is 4.1%.

Denial rate

2.7%

11,752 of 436,009 claims

Appeals overturned

44.8%

69 of 154 filed

External review overturned

n/a

not reported

Prior file (plan year 2025, 2023 claims): denial rate 1.5% (6,325 of 433,953); appeal overturn rate 54.7%.

Compared with South Dakota and the national median

Measure	Avera Health Plans, Inc.	South Dakota median	National median
In-network denial rate	2.7%	4.1%	19.0%
In-network claims received	436,009	—	—
Internal appeals filed	154	—	—
Internal appeal overturn rate	44.8%	44.8%	37.7%
External reviews filed	n/a	—	—
External review overturn rate	n/a	n/a	0.0%
Out-of-network denial rate	78.1%	—	—

Medians are across issuers with at least 1,000 in-network claims received in the same file (South Dakota: 3 issuers; national: 158 issuers in 32 states). Plan year 2026 file, 2024 claims.

Read these numbers carefully

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), plan year 2026; data dictionary. Issuer's own claims-payment policy page: https://www.averahealthplans.com/insurance/.

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.

Compare this issuer

Other issuers in South Dakota

Sanford Health Plan 4.1%
Wellmark of South Dakota 15.4%

Plans in this filing (35)

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	516
60536SD0020018	PPO	Catastrophic	34
60536SD0020023	PPO	Bronze	974
60536SD0020024	PPO	Bronze	1,033
60536SD0020041	PPO	Gold	45
60536SD0020046	PPO	Bronze	325
60536SD0020047	PPO	Bronze	86
60536SD0020050	PPO	Catastrophic	n/a
60536SD0020051	PPO	Gold	136
60536SD0020052	PPO	Silver	2,186
60536SD0020057	PPO	Gold	n/a
60536SD0020058	PPO	Silver	74
60536SD0020066	PPO	Bronze	1,186
60536SD0020067	PPO	Bronze	122
60536SD0020068	PPO	Gold	n/a
60536SD0020069	PPO	Gold	n/a
60536SD0020070	PPO	Silver	n/a
60536SD0020071	PPO	Silver	n/a
60536SD0020072	PPO	Gold	n/a
60536SD0020073	PPO	Gold	n/a
60536SD0020074	PPO	Silver	n/a
60536SD0020075	PPO	Silver	n/a
60536SD0020076	PPO	Silver	n/a
60536SD0020077	PPO	Silver	n/a
60536SD0060014	HMO	Bronze	387
60536SD0060015	HMO	Bronze	279
60536SD0060017	HMO	Gold	154
60536SD0060018	HMO	Silver	638
60536SD0060021	HMO	Bronze	746
60536SD0060022	HMO	Gold	35
60536SD0060027	HMO	Gold	n/a
60536SD0060028	HMO	Silver	n/a
60536SD0060030	HMO	Gold	n/a
60536SD0060031	HMO	Silver	n/a
60536SD0060032	HMO	Silver	n/a

Questions

What counts as a "denied" claim in Avera Health Plans, Inc.'s 2.7% rate?

Every in-network claim the issuer reported as denied in the 2024 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 2024 when the file is for plan year 2026?

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 (4.1%) 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, 44.8% of internal appeals to this issuer were overturned (69 of 154). If the internal appeal fails, independent external review is available.

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Cite: Apellica Insurer Denial Report Cards, Avera Health Plans, Inc. (South Dakota), plan year 2026, 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.