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.

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