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.

• Anthem Blue Cross

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

• Blue Shield of California

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

* These volumes do not include pediatric dental or vision claims.

• CCHP Health Plan

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: Information to Come
2018 Total Claims Denied: Information to Come

2018 Plan Level Claims: Information to Come


• 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
• 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
• Kaiser Permanente

Kaiser is not a claims based model, therefore not applicable.


• LA Care Health Plan

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

• Molina Healthcare

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

• Oscar

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

• Sharp Health Plan

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: Information to Come
2018 Total Claims Denied: Information to Come

2018 Plan Level Claims: Information to Come

• Valley Health Plan

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

• 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