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 the calendar year. 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.
  • Plan level claim denials are reported beginning Plan Year 2018.

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

    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

    2018 Plan Level Claims

    • 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
    • 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

    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

    2018 Plan Level Claims

    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

    2018 Plan Level Claims

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