Data on Appeals

Appeals in 2019

Anthem Blue Cross:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 423
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 338
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 4
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 1

Blue Shield of California*:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 12,241 Individual, 219 Small Business
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 4,472 Individual, 7 Small Business
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 193 Individual, 7 Small Business
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 112 Individual, 3 Small Business
  • Note: Blue Shield does not currently include the Date of Service in appeal reporting data

CCHP Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 171 Individual, 5 Small Business
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 114 Individual, 1 Small Business
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 6 Individual, 1 Small Business
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 2 Individual, 0 Small Business

Health Net:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019 Health Net Life: 2,132 Individual, 652
  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019 Health Net CA: 1,736 Individual
  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019 Health Net Small Business: 652
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals, Health Net Life: 997 Individual
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals, Health Net CA: 990 Individual
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals, Health Net Small Business: 305
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019, Health Net Life: 399 Individual
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019, Health Net CA: 363 Individual
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019, Health Net Small Business: 10
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals, Health Net Life: 2 Individual
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals, Health Net CA: 3 Individual
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals, Health Net Small Business: 0

Kaiser Permanente:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 553
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 469
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 29
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 7

LA Care Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 6,632
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 2,375
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 4
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 3

Molina Healthcare:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 135 Appeals (Clinical), 327 Appeals (Non-Clinical)
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 54 Appeals Overturned (Clinical), 37 Appeals Overturned (Non-Clinical)
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 9 Independent Medical Reviews (Clinical)
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 6 Independent Medical Reviews overturned (Clinical)

Oscar:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 1,195
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 401
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 10
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 5

Sharp Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 108
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 32
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 22
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 1

Valley Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 106
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 52
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 32
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 15

Western Health Advantage:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2019: 73
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2019 Appeals: 24
  • Number of Issuer Level External Appeals Filed in Calendar Year 2019: 4
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2019 Appeals: 1

    Anthem Blue Cross:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 718
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 400
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 15
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 8

    Blue Shield of California*:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 10,516
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 3,955
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 214
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 96

    *Blue Shield does not currently include the Date of Service in appeal reporting data

    CCHP Health Plan:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 146 Individual, 1 Small Business
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 95 Individual, 1 Small Business
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 8 Individual, 0 Small Business
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 1 Individual, 0 Small Business

    Health Net:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 2,406 Individual, 626 Small Business
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 1,379 Individual, 314 Small Business
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 19 Individual, 0 Small Business
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 10 Individual, 0 Small Business

    Kaiser Permanente:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 1,214
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 1,105
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 13
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 2

    LA Care Health Plan:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: N/A
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: N/A
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: N/A
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: N/A

    Molina Healthcare:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 160 Appeals (Clinical) 339 Appeals (Non-Clinical)
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 62 Appeals Overturned (Clinical) 43 Appeals Overturned (Non-Clinical)
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 12 Independent Medical Reviews (Clinical)
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 9 Independent Medical Reviews overturned (Clinical)

    Oscar:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 218
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 79
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 6
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 2

    Sharp Health Plan:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 169
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 37
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 24
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 7

    Valley Health Plan:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 157
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 31
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 29
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 12

    Western Health Advantage:

    • Number of Issuer Level Internal Appeals Filed in Calendar Year 2018: 80
    • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2018 Appeals: 24
    • Number of Issuer Level External Appeals Filed in Calendar Year 2018: 22
    • Number of Issuer Level External Appeals Overturned from Calendar Year 2018 Appeals: 3

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