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 calendar year 2015. 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.

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

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

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

Health Net:

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

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

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

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

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

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

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

Western Health Advantage: Plan level hospital claims that WHA is responsible for paying are out-of-area urgent and/or emergency claims.

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

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