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:

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

    2018 Plan Level Claims

    2019 Total Claims Received: 2,096,919
    2019 Total Claims Denied: 401,320

    2019 Plan Level Claims

    2020 Total Claims Received: 2,671,617
    2020 Total Claims Denied: 537,071

    2020 Plan Level Claims

Qualified Dental Plan

     2020 Total Claims Received: 69,972
    2020 Total Claims Denied: 4,155

    2020 Plan Level Claims

• Blue Shield of California:

Individual Market

    2016 Total Claims Received: 11,440,660
    2016 Total Claims Denied: 494,299

    2017 Total Claims Received: 19,972,661
    2017 Total Claims Denied: 4,086,853

    2018 Total Claims Received: 13,679,205
    2018 Total Claims Denied: 4,007,226

    2018 Plan Level Claims

2019 Total Claims Received: 15,076,796
2019 Total Claims Denied: 4,952,371

    2019 Plan Level Claims for Individual and Small Business Markets

2020 Total Claims Received: 20,980,361
2020 Total Claims Denied: 3,935,336

    2020 Plan Level Claims for Individual Market

Covered California for Small Business

2019 Total Claims Received: 675,405
2019 Total Claims Denied: 159,913

    2019 Plan Level Claims for Individual and Small Business Markets 

2020 Total Claims Received: 661,453
2020 Total Claims Denied: 107,382

    2020 Plan Level Claims for Small Business Markets

Qualified Dental Plan

    Blue Shield entered the Dental market in 2021, 2020 data not available.

• CCHP Health Plan:

Individual Market

    2016 Total Claims Received: 130,290
    2016 Total Claims Denied: 18,510

    2017 Total Claims Received: 121,410
    2017 Total Claims Denied: 19,733

2018 Total Claims Received: 40,306
2018 Total Claims Denied: 3,551

    2019 Total Claims Received: 247,315
    2019 Total Claims Denied: 27,640

    2019 Plan Level - Individual Market

    2020 Total Claims Received: 73
    2020 Total Claims Denied: 6

    2020 Plan Level Claims

Covered California for Small Business:

2018 Total Claims Received: 644
2018 Total Claims Denied: 63

    2018 Plan Level Claims for Individual and Small Business Markets

    2019 Plan Level - Covered California for Small Business

    2020 Total Claims Received: 3
    2020 Total Claims Denied: 0

    2020 Plan Level Claims for Individual and Small Business Markets

Pharmacy Claims

    2020 Total Claims Received: 52,721
    2020 Total Claims Denied: 7,572

    2020 Plan Level – Pharmacy Claims

• California Dental Network:

2020 Total Claims Received:  Information to Come
2020 Total Claims Denied: Information to Come

2020 Plan Level Claims for Individual Market - Information to Come

• Delta Dental:

Individual Market

    2020 Total Claims Received:  416,838 
    2020 Total Claims Denied: 106,743

    2020 Plan Level Claims for Individual Market

Covered California for Small Business

    2020 Total Claims Received: 12,782
    2020 Total Claims Denied: 2,626

    2020 Plan Level Claims for Small Business Market

• Dental Health Services:

Individual Market

2020 Total Claims Received: 10,350
2020 Total Claims Denied: 1,141.

2020 Plan Level Claims

Covered California for Small Business

2020 Total Claims Received: 58
2020 Total Claims Denied: 12

• Health Net:

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

    2020 Plan Level Claims for Small Business Market

• Kaiser Permanente:

Individual Market Northern California:

2019 Total Claims Received: 45,577
2019 Total Claims Denied: 3,333

Individual Market Southern California:

2019 Total Claims Received: 118,010
2019 Total Claims Denied: 7,848

2019 Plan Level Claims for Individual Market

Covered California for Small Business Northern California:

2019 Total Claims Received: 3,105
2019 Total Claims Denied: 315

Covered California for Small Business Southern California:

2019 Total Claims Received: 6,991
2019 Total Claims Denied: 510

2019 Plan Level Claims for Small Business Market

Individual Market

    2020 Total Claims Received: 343,894
    2020 Total Claims Denied: 21,827

    2020 Plan Level Claims for Individual Market

Covered California for Small Business

    2020 Total Claims Received: 23,041
    2020 Total Claims Denied: 1,205

    2020 Plan Level Claims for Small Business Market

• LA Care Health Plan:

Individual Market

2016 Total Claims Received: 138,702
2016 Total Claims Denied: 40,714

2017 Total Claims Received: 588,009
2017 Total Claims Denied: 138,741

2018 Total Claims Received: 399,749
2018 Total Claims Denied: 225,330

2018 Plan Level Claims

2019 Total Claims Received: 925,611
2019 Total Claims Denied: 324,593

2019 Plan Level Claims

2020 Total Claims Received: 751,782
2020 Total Claims Denied: 324,593

2020 Plan Level Claims for Individual Market

• Liberty Dental Plan:

Individual Market

    2020 Total Claims Received: 36,986
    2020 Total Claims Denied: 10,090

    2020 Plan Level Claims for Individual Market

Small Business Market

    2020 Total Claims Received: 117
    2020 Total Claims Denied: 55

    2020 Plan Level Claims for Small Business Market

• Molina Healthcare:

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

    2018 Plan Level Claims

    2019 Total Claims Received: 805,494
    2019 Total Claims Denied: 253,330

    2019 Plan Level Claims

    2020 Total Claims Received: 833,048  
    2020 Total Claims Denied: 339,905 

   2020 Plan Level Claims for Individual Market

• Oscar:

Individual Market

2016 Total Claims Received: 66,294
2016 Total Claims Denied: 11,493

2017 Total Claims Received: 179,770
2017 Total Claims Denied: 21,883

2018 Total Claims Received: 336,279
2018 Total Claims Denied: 50,394

2018 Plan Level Claims

2019 Total Claims Received: 210,468
2019 Total Claims Denied: 12,670

2019 Plan Level Claims

2020 Total Claims Received: 101,910
2020 Total Claims Denied: 47,514

2020 Plan Level Claims for Individual Market

• Sharp Health Plan:

Individual Market

    2016 Total Claims Received: 365,452
    2016 Total Claims Denied: 61,367

    2017 Total Claims Received: 477,165
    2017 Total Claims Denied: 83,844

    2018 Total Claims Received: 681,384
    2018 Total Claims Denied: 107,076

    2018 Plan Level Claims

    2019 Total Claims Received: 397,846
    2019 Total Claims Denied: 69,493

    2019 Plan Level Claims

    2020 Total Claims Received: 703,496
    2020 Total Claims Denied: 64,283

    2020 Plan Level Claims

Pharmacy

    2020 Total Claims Received: 231,786 Individual; 45,716 Small Group 
    2020 Total Claims Denied: 59,506 Individual; 11,016 Small Group

    2020 Plan Level Claims for Individual Market

    2020 Plan Level Claims for Small Business Market

• Valley Health Plan:

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

2018 Plan Level Claims

2019 Total Claims Received: 91,561
2019 Total Claims Denied: 9,070

2019 Plan Level Claims

2020 Total Claims Received: 279,096  
2020 Total Claims Denied: 29,464 

2020 Plan Level Claims for Individual Market

• Western Health Advantage (WHA):

WHA is unable to provide complete claims denial data. Under WHA's fully-delegated model of care, our delegated entities (medical groups, IPAs, hospitals, ancillary providers) do not provide WHA with claims denial data. WHA’s claim denial data is limited to the claims processed directly by the health plan and those are specific to out of area emergency and urgent claims.

2016 Total Claims Received: 2,116
2016 Total Claims Denied: 157

2017 Total Claims Received: 2,804
2017 Total Claims Denied: 200

2018 Total Claims Received: 4,250
2018 Total Claims Denied: 224

2018 Plan Level Claims

2019 Total Claims Received: 4,143
2019 Total Claims Denied: 407

2019 Plan Level Claims

2020 Total Claims Received: 4,271  
2020 Total Claims Denied: 360 

2020 Plan Level Claims for Individual Market