Most plan-reported denials (77%) were classified as ‘all other reasons.’Īs in our previous analysis of claims denials, we find that consumers rarely appeal denied claims and when they do, insurers usually uphold their original decision. Of in-network claims, about 14% were denied because the claim was for an excluded service, 8% due to lack of preauthorization or referral, and only about 2% based on medical necessity. Insurer denial rates varied widely around this average, ranging from 2% to 49%.ĬMS requires insurers to report the reasons for claims denials at the plan level. We find that, across insurers with complete data, nearly 17% of in-network claims were denied in 2021. Data were reported by insurers for the 2021 plan year and posted in a public use file in October 2022. ![]() If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.In this brief, we analyze transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for non-group qualified health plans (QHPs) offered on. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. Availity provides administrative services to BCBSIL.
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