Data on Appeals

    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

    Appeals in 2019

    Anthem Blue Cross:

    Individual Market:

    • 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

Appeals in 2020

Anthem Blue Cross:

Individual Market:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 862
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020 : 505
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 18
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 13

Qualified Dental Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 219
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 105
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 0
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 0

Blue Shield of California*:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 12,579 Individual, 294 Small Business
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 4,213 Individual, 94 Small Business
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 220 Individual, 9 Small Business
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 151 Individual, 8 Small Business

CCHP Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 73
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 0
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 0
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 0

California Dental Network:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 0 Individual, 0 Small Business
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 0 Individual, 0 Small Business
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 0 Individual, 0 Small Business
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 0 Individual, 0 Small Business

Delta Dental:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 166 Individual, 4 Small Business
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020 Appeals: 65 Individual, 0 Small Business
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 20 Individual, 0 Small Business
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020 Appeals: 13 Individual, 0 Small Business

Dental Health Services:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 0
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 0
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 0
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 0

Health Net:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020, Health Net Life: 2,576 Individual
  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020, Health Net CA: 2,250 Individual
  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020, Health Net Small Business: 46
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020 Health Net Life: 1,206 Individual
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020, Health Net CA: 1,291 Individual
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020, Health Net Small Business: 24
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020, Health Net Life: 323 Individual
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020, Health Net CA: 504 Individual
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020, Health Net Small Business: 0
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020,Health Net Life: 6 Individual
  • Number of Issuer Level External Appeals Overturned from Calendar Year 22020, Health Net CA: 5 Individual
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020, Health Net Small Business: 0

Kaiser Permanente:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 185
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 61
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 1
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020 : 1

LA Care Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 665
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 402
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 9,051
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 3,505

Liberty Dental Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 15 Individual, 0 Small Business
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 5 Individual, 0 Small Business
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 0 Individual
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 0 Individual

Molina Healthcare:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 540
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 95
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 1
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 1

Oscar:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 82
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 79
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 10
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 10

Sharp Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 109 Individual and Small Group; Pharmacy Individual; 75, Pharmacy Small Group 15
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 30 Individual and Small Group; Pharmacy Individual; 42, Pharmacy Small Group 10
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 29 Individual and Small Group; Pharmacy Individual 0, Pharmacy Small Group 0
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 12 Individual and Small Group; Pharmacy Individual 0, Pharmacy Small Group 0

Valley Health Plan:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 138
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 58
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 12
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 4

Western Health Advantage:

  • Number of Issuer Level Internal Appeals Filed in Calendar Year 2020: 99
  • Number of Issuer Level Internal Appeals Overturned from Calendar Year 2020: 39
  • Number of Issuer Level External Appeals Filed in Calendar Year 2020: 7
  • Number of Issuer Level External Appeals Overturned from Calendar Year 2020: 1

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