Data on Denied Claims

Qualified Health Plan Issuers have provided annual data for total claims received and denied.

Claims received are defined as the number of claims received by an issuer asking for a payment or reimbursement by or on behalf of an in-network health care provider (such as a hospital or doctor) that is contracted to be part of the network for an issuer.

  • A claim means any individual line of service within a bill for services (medical and pharmacy).
  • Do not include claims that were pended for additional information and subsequently paid.
  • Do not include out-of-network claims.

Claims denied are a received claim that the issuer subsequently denied.

  • Include all denials in the total number of claims denied in calendar year 2015. This includes, but is not limited to:
    • Pediatric vision and dental denials;
    • Partial denials;
    • Denials due to ineligibility;
    • Denials due to incorrect submission;
    • Denials for incorrect billing; and
    • Duplicate claims.

Click the links below to see the information the issuers have provided.

Anthem Blue Cross:

2015 Total Claims Received: 2,754,870
2015 Total Claims Denied: 779,993

2016 Total Claims Received: 2,652,690
2016 Total Claims Denied: 692,148

Blue Shield of California:

2015 Total Claims Received: 8,843,536
2015 Total Claims Denied: 438,552

2016 Total Claims Received: 11,440,660
2016 Total Claims Denied: 494,299

CCHP Health Plan: Issuer was not able to separate out-of-network claims.

2015 Total Claims Received: 415,843
2015 Total Claims Denied: 17,414

2016 Total Claims Received: 381,170
2016 Total Claims Denied: 16,128

Health Net:

2015 Total Claims Received: 5,770,590
2015 Total Claims Denied: 470,429

2016 Total Claims Received: 3,793,128
2016 Total Claims Denied: 345,450

Kaiser Permanente:

Kaiser is not a claims based model, therefore not applicable.

LA Care Health Plan:

2015 Total Claims Received: 116,070
2015 Total Claims Denied: 31,409

2016 Total Claims Received: 138,702
2016 Total Claims Denied: 40,714

Molina Healthcare:

2015 Total Claims Received: 91,726
2015 Total Claims Denied: 21,180

2016 Total Claims Received: 407,542
2016 Total Claims Denied: 106,879

Oscar: 2016 was the first year offered

2016 Total Claims Received: 32,823
2016 Total Claims Denied: 4,639

Sharp Health Plan:

2015 Total Claims Received: 272,686
2015 Total Claims Denied: 41,578

2016 Total Claims Received: 365,452
2016 Total Claims Denied: 61,367

Valley Health Plan:

2015 Total Claims Received: 16,290
2015 Total Claims Denied: 4,696

2016 Total Claims Received: 26,312
2016 Total Claims Denied: 7,713

Western Health Advantage:

2015 Total Claims Received: 1,410
2015 Total Claims Denied: 107

2016 Total Claims Received: 2,116
2016 Total Claims Denied: 157