Data on Denied Claims
Qualified Health and Dental 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, doctor, or dentist) 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, oral 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 the calendar year. This includes, but is not limited to:
- Medical claim pediatric vision and pediatric dental denials;
- Partial denials;
- Denials due to ineligibility;
- Denials due to incorrect submission;
- Denials for incorrect billing; and
- Duplicate claims.
- Plan level claim denials are reported beginning Plan Year 2018.
Click the links below to see the information the issuers have provided.
- Anthem Blue Cross:
- Blue Shield of California:
- CCHP Health Plan:
- California Dental Network:
- Delta Dental:
- Dental Health Services:
- Health Net:
- Kaiser Permanente:
- LA Care Health Plan:
- Liberty Dental Plan:
- Molina Healthcare:
- Oscar:
- Sharp Health Plan:
- Valley Health Plan:
- Western Health Advantage (WHA):
Individual Market
2016 Total Claims Received: 7,379,867
2016 Total Claims Denied: 2,422,282
2017 Total Claims Received: 5,634,611
2017 Total Claims Denied: 1,731,253
2018 Total Claims Received: 2,331,417
2018 Total Claims Denied: 629,010
2019 Total Claims Received: 2,096,919
2019 Total Claims Denied: 401,320
2020 Total Claims Received: 2,671,617
2020 Total Claims Denied: 537,071
Qualified Dental Plan
2020 Total Claims Received: 69,972
2020 Total Claims Denied: 4,155
Individual Market
2016 Total Claims Received: 4,193,245
2016 Total Claims Denied: 1,064,132
2017 Total Claims Received: 4,196,039
2017 Total Claims Denied: 983,962
2018 Total Claims Received: 4,869,669
2018 Total Claims Denied: 1,235,568
2018 Plan Level Claims for Individual and Small Business Markets
2019 Total Claims Received Health Net CA: 4,360,370
2019 Total Claims Received Health Net Life: 1,391,757
2019 Total Claims Denied Health Net CA: 1,069,370
2019 Total Claims Denied Health Net Life: 285,738
2019 Plan Level Claims for Individual Market
2020 Total Claims Received Health Net CA: 2,980,962
2020 Total Claims Received Health Net Life: 639,095
2020 Total Claims Denied Health Net CA: 974,647
2020 Total Claims Denied Health Net Life: 222,044
2020 Plan Level Claims for Individual Market HNL
2020 Plan Level Claims for Individual Market HNCA
Covered California for Small Business:
2016 Total Claims Received: 202,531
2016 Total Claims Denied: 37,668
2017 Total Claims Received: 163,893
2017 Total Claims Denied: 31,749
2018 Total Claims Received: 86,951
2018 Total Claims Denied: 16,969
2018 Plan Level Claims for Individual and Small Business Markets
2019 Total Claims Received: 82,902
2019 Total Claims Denied: 15,774
2019 Plan Level Claims for Small Business Market
2020 Total Claims Received Health Net Life: 27,678
2020 Total Claims Denied Health Net Life: 10,461
Individual Market
2016 Total Claims Received: 407,542
2016 Total Claims Denied: 106,879
2017 Total Claims Received: 1,795,165
2017 Total Claims Denied: 726,164
2018 Total Claims Received: 798,487
2018 Total Claims Denied: 267,100
2019 Total Claims Received: 805,494
2019 Total Claims Denied: 253,330
2020 Total Claims Received: 833,048
2020 Total Claims Denied: 339,905
Individual Market
2016 Total Claims Received: 26,312
2016 Total Claims Denied: 7,713
2017 Total Claims Received: 53,166
2017 Total Claims Denied: 16,402
2018 Total Claims Received: 99,350
2018 Total Claims Denied: 19,783
2019 Total Claims Received: 91,561
2019 Total Claims Denied: 9,070
2020 Total Claims Received: 279,096
2020 Total Claims Denied: 29,464
Consumer Information
- Information on Cost-Sharing and Payments With Respect To Out-of-Network Coverage
- Enrollee Rights Information Under Title I of the Affordable Care Act
Quality Ratings
Claims
Data and Enrollment
- Data on Enrollment
- Data on Disenrollment
- Data on Rating Practices
- Data on Denied Claims
- Data on Appeals
Financial Information
Rate Booklet
- Covered California's Health Insurance Companies and Plan Rates for 2022
- 2020 Health Plan Rate Booklet
- 2019 Health Plan Rate Booklet
- 2021 Family Dental Rate Booklet
- 2020 Family Dental Rate Booklet
Contracts
- QHP Individual Market Model Contract for 2017-2022 - Amended for 2022
- QHP Individual Market Attachment 7 for 2017-2022 - Amended for 2022
- QHP Individual Market Attachment 14 for 2017-2022 - Amended for 2022
- QDP Model Contract for 2017-2022 - Amended for 2022
- QDP Attachment 3 for 2017-2022 - Amended for 2022
- QDP Attachment 7 for 2017-2022 - Amended for 2022
- QDP Attachment 14 for 2017-2022 - Amended for 2022
- CCSB QHP Model Contract for 2017-2022 - Amended for 2022
- CCSB Attachment 3 for 2017-2022 - Amended for 2022
- CCSB Attachment 7 for 2017-2022 - Amended for 2022
- CCSB Attachment 14 for 2017-2022 - Amended for 2022
- QHP Model Contract for 2017-2021 – Amended for 2021
- QDP Model Contract for 2017-2021 – Amended for 2021
- CCSB Model Contract for 2017-2021 – Amended for 2021
- CCSB Attachment 3 2017-2021 – Amended for 2021
- CCSB Attachment 7 2017-2021 – Amended for 2021
- CCSB Attachment 14 2017-2021 – Amended for 2021
- Attachment 7 for the Individual Market 2017-2021 – Amended for 2021
- Attachment 14 for for the Individual Market 2017-2021 – Amended for 2021
- QHP Model Contract for 2017-2020 – Amended for 2020
- QDP Model Contract for 2017-2020 – Amended for 2020
- CCSB Model Contract for 2017-2020 – Amended for 2020
- Attachment 7 for 2017-2020 – Amended for 2020
- Attachment 14 for 2017-2020 – Amended for 2020
- QHP Model Contract for 2017-2019 – Amended for 2019
- QDP Model Contract for 2017-2019 – Amended for 2019
- CCSB Model Contract for 2017-2019 – Amended for 2019
- Attachment 7 for 2017-2019 - Amended for 2019
- Attachment 14 for 2017-2019 – Amended for 2019
- QHP Model Contract 2017-2019 – Amended for 2017 and 2018
- QDP Model Contract 2017-2019 – Amended for 2017 and 2018
- CCSB Model Contract 2017-2019 – Amended for 2017 and 2018
- Attachment 7 – Amended for 2017 and 2018
- QHP Model Contract for 2017-2019
- QDP Model Contract for 2017-2019
- CCSB Model Contract for 2017-2019