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

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

    2019 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

    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

    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 Busuiness 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

    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

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