02 · Denials

Who says no, and what happens next

7,350,316 standard requests were denied across the 523 filings that publish counts (of 658), a 11.0% rateⓘ. Four ways to read that number: whether urgent requests fare better or worse and how long decisions take, who issued the denials, whether size changes the rate, and how many denials were ever tested on appeal.

01 · Urgent requests and the clock

When the request is urgent

Expedited requests are the ones a doctor marked as time-critical, and the rule puts a clock on both kinds of decisionⓘ. Four pictures of what payers published against it: how long standard and expedited decisions actually take, whether urgent requests are denied more often than routine ones, and whether a filing's own mean and median tell the same story.

177

of 424 filings deny expedited requests more often than standard ones

publish a standard mean over 7 days the filings

publish an expedited mean over 72 hours the filings

220

publish a mean more than three times their own median, or the reverseⓘ

Standard decisions click a bar for its filings

Published mean time to decision, against the 7-day clock · 629 filings publish one

190

102

186

0–1

1–2

2–3

3–5

5–7

over 7

days; the orange bar is past the clock.

Expedited decisions click a bar for its filings

Published mean time to decision, against the 72-hour clock · 585 filings publish one

146

223

0–6

6–12

12–24

24–48

48–72

over 72

hours; the orange bar is past the clock.

Urgent against routine, 424 filings with 100+ expedited requests click a point for the filing

Standard denial rate across, expedited denial rate up, both to 60%. The dashed line is where the two agree; every point above it is a plan that says no more often when the doctor said it was urgent.

015%30%45%60% standard denial rate

● 177 deny urgent requests more often ● 247 deny them less often

The widest gaps

Percentage points by which the expedited rate exceeds the standard rate in the same filing.

Humana Healthy Horizons in South…
Humana +48.6 Humana Healthy Horizons in…
Humana +46.8 Johns Hopkins Advantage MD (PPO)…
Johns Hopkins Medicine +43.7 Johns Hopkins Advantage MD (HMO)…
Johns Hopkins Medicine +40.3 Humana Healthy Horizons in Florida
Humana +38.3 UnitedHealthcare Medicare…
UnitedHealth Group +33.0 UnitedHealthcare Medicare…
UnitedHealth Group +26.3 Humana Healthy Horizons in…
Humana +25.6 Humana Healthy Horizons in…
Humana +24.1 Arizona Long Term Care
UnitedHealth Group +23.8

Standard: mean against median click a point for the filing

The two figures a filing publishes for the same standard decisions. Median across, mean up, both on a log scale. On the dashed line the two agree; far from it, one filing's two figures do not.

the clock — 7 days, both axes

0110100 days

● mean past the clock ● mean and median three times apart ● 615 filings publish both ● 176 published a zero — drawn on the axis

Expedited: mean against median click a point for the filing

The two figures a filing publishes for the same expedited decisions. Median across, mean up, both on a log scale. On the dashed line the two agree; far from it, one filing's two figures do not.

the clock — 72 hours, both axes

01101001000 hours

● mean past the clock ● mean and median three times apart ● 583 filings publish both ● 230 published a zero — drawn on the axis

The filings behind the charts

Expedited denied more often than standard, the widest gaps

Plan

Organization

Standard

Expedited

Std mean · median

Exp mean · median

Gap

Humana Healthy Horizons in South Carolina Medicaid Managed Care

Humana Healthy Horizons in Oklahoma Medicaid Managed Care

Johns Hopkins Advantage MD (PPO) - Contract H3890 Medicare Advantage

Johns Hopkins Medicine

Johns Hopkins Advantage MD (HMO) - Contract H1225 Medicare Advantage

Johns Hopkins Medicine

Humana Healthy Horizons in Florida Medicaid Managed Care

UnitedHealthcare Medicare Advantage - Contract H3794 Medicare Advantage

UnitedHealthcare Medicare Advantage - Contract H7464 Medicare Advantage

Humana Healthy Horizons in Louisiana Medicaid Managed Care

Humana Healthy Horizons in Virginia Medicaid Managed Care

Arizona Long Term Care Medicaid Managed Care

UnitedHealthcare Medicare Advantage - Contract H3387 Medicare Advantage

Medicaid Managed Care Medicaid Managed Care

Against the clock, and against themselves

Plan

Organization

Standard

Expedited

Std mean · median

Exp mean · median

Flag

Community Health Choice CHIP & CHIP Perinatal (combined) CHIP Managed Care

Community Health Choice

—

9.0 · 3.0 d

288.0 · 72.0 h

standard mean over 7 days
expedited mean over 72 hours
mean and median three times apart

VillageCareMAX Managed Long-Term Care Medicaid Managed Care

standard mean over 7 days
expedited mean over 72 hours
mean and median three times apart

Mississippi Medicaid Fee-for-Service Medicaid FFS

Mississippi Division of Medicaid

—

3.1 · 1.0 d

110.3 · 27.0 h

expedited mean over 72 hours
mean and median three times apart
mean and median three times apart

Colorado Access Medicaid Managed Care

standard mean over 7 days
mean and median three times apart

Umpqua Health Alliance Medicaid Managed Care

standard mean over 7 days
expedited mean over 72 hours

California Children's Services (CCS) Medicaid FFS

standard mean over 7 days
mean and median three times apart

Hamaspik Choice (MLTC) Medicaid Managed Care

standard mean over 7 days
expedited mean over 72 hours

Mass General Brigham Advantage Secure HMO-POS Medicare Advantage

standard mean over 7 days
mean and median three times apart

Humana Healthy Horizons in Indiana Medicaid Managed Care

mean and median three times apart
mean and median three times apart

AZ Blue Health Choice (AHCCCS) Medicaid Managed Care

Blue Cross Blue Shield of Arizona

—

4.0 · 1.1 d

16.1 · 2.8 h

mean and median three times apart
mean and median three times apart

Kaiser Foundation Health Plan of the Northwest Medicare Advantage

mean and median three times apart
mean and median three times apart

Individual Affordable Care Act Plan Members Marketplace QHP

Blue Cross Blue Shield of Arizona

—

3.5 · 0.3 d

20.4 · 2.9 h

mean and median three times apart
mean and median three times apart

02 · Who denies the most

Organizations, by denials issued

Standard denials summed across every filing the organization published that carries counts. The rate beside each is that organization's own volume-weighted rate.

UnitedHealth Group · 110 filings 1.3M 12.8% California DHCS · 3 filings 1.1M 28.9% Centene · 60 filings 1.1M 12.2% Humana · 42 filings 733K 6.8% Colorado HCPF · 1 filing 390K 22.3% Wellcare · 37 filings 325K 16.2% Ohio Department of Medicaid · 3 filings 241K 17.3% Healthfirst · 9 filings 240K 13.6% AmeriHealth Caritas · 6 filings 193K 23.4% Virginia DMAS · 1 filing 177K 24.4% CVS Health / Aetna · 15 filings 149K 16.0% Elevance Health · 7 filings 145K 9.1% CareSource · 2 filings 127K 19.1% Kaiser Permanente · 18 filings 94K 9.9% Blue Cross Blue Shield of Michigan · 1 filing 85K 34.9% AmeriHealth Caritas Family of Companies · 8 filings 63K 21.1% Sentara Health · 3 filings 60K 15.1% Priority Health · 5 filings 45K 12.4% L.A. Care Health Plan · 2 filings 43K 1.8% Inland Empire Health Plan · 3 filings 42K 1.2% SCAN Health Plan · 1 filing 38K 1.8% Highmark · 15 filings 37K 4.2% Excellus BlueCross BlueShield · 6 filings 37K 9.6% EmblemHealth · 5 filings 33K 16.7% UCare · 9 filings 31K 41.0% CountyCare Health Plan (Cook County Health) · 1 filing 24K 10.0% California Department of Health Care Services · 1 filing 22K 28.4% Independent Health · 3 filings 22K 13.4% Alignment Healthcare · 7 filings 21K 2.3% Managed Health Services · 1 filing 20K 25.7%

Highest rates, organizations with 10,000+ requestsⓘ

UCare 41.0% 75K Blue Cross Blue Shield of Michigan 34.9% 243K California DHCS 28.9% 4.0M California Department of Health Care Services 28.4% 79K Managed Health Services 25.7% 79K SilverSummit Healthplan 24.7% 32K Virginia DMAS 24.4% 724K Nebraska Total Care 24.2% 53K AmeriHealth Caritas 23.4% 827K Colorado HCPF 22.3% 1.7M

Plans with the most denials

Plan

Market

State

Requests

Denied

Rate

Medi-Cal Dental Fee-for-ServiceCalifornia DHCS

UnitedHealthcare Medicare Advantage - Contract H2001UnitedHealth Group

Health First Colorado / CHP+ (13 PA programs combined)Colorado HCPF

Ohio Medicaid Managed Care - all plans combinedOhio Department of Medicaid

Medicaid Managed Care

1,175,861

222,965

19.0%

California Children's Services (CCS)California DHCS

Virginia Medicaid Fee-for-Service (Cardinal Care FFS)Virginia DMAS

Medicaid Managed CareHealthfirst

Medicaid Managed Care

750,763

147,742

19.7%

UnitedHealthcare Medicare Advantage - Contract H5253UnitedHealth Group

CareSource Ohio MedicaidCareSource

Medicaid Managed Care

603,377

120,676

20.0%

Denial rate by stateⓘ

click a state for its filings

≤ 7.0%7.0% – 12.6%12.6% – 16.0%16.0% – 18.5%> 18.5%not published

Explore this map

Volume-weighted denial rate per state. Switch the map to raw denial counts — where the volume is — or to filing counts, which shows where disclosure itself is thin rather than where denials are common.

Explore a state's filings

Highest — standard denial rate

Minnesota33.0%Alabama28.5%North Dakota22.4%Colorado21.5%South Carolina21.3%

Lowest

Idaho0.7%Alaska2.1%Utah2.8%

Each state opens the filings its figure was computed from.

03 · Scale and scrutiny

Does a bigger plan say no more often?

Every filing with 100 or more standard requests: request volume across (log scale), denial rate up, coloured by market. A plan far above its neighbours of the same size and market is the one to read.

Denial rate against request volume, 516 filings click a point for the filing

1001K10K100K1M requests

● Medicare Advantage● Medicaid Managed Care● Medicaid FFS● Marketplace QHP● CHIP

Median rate by market and size bandⓘ

Medicaid Managed Care 100–1K 15.6% 2

Medicaid Managed Care 1K–10K 11.3% 28

Medicaid Managed Care 10K–100K 12.1% 99

Medicaid Managed Care 100K+ 14.9% 52

Medicaid FFS 1K–10K 5.2% 2

Medicaid FFS 10K–100K 10.3% 8

Medicaid FFS 100K+ 6.4% 11

CHIP Managed Care 100–1K 9.0% 6

CHIP Managed Care 1K–10K 16.6% 11

CHIP Managed Care 10K–100K 14.5% 3

Medicare Advantage 100–1K 9.2% 25

Medicare Advantage 1K–10K 10.0% 49

Medicare Advantage 10K–100K 11.9% 99

Medicare Advantage 100K+ 7.8% 51

Marketplace QHP 100–1K 15.9% 2

Marketplace QHP 1K–10K 12.2% 13

Marketplace QHP 10K–100K 22.0% 25

Marketplace QHP 100K+ 9.8% 7

Unclassified 1K–10K 22.4% 2

Unclassified 10K–100K 17.7% 7

Unclassified 100K+ 18.2% 1

Multiple (combined) 10K–100K 6.3% 2

Multiple (combined) 100K+ 9.9% 1

Medicare-Medicaid Plan 100–1K 40.4% 1

Medicare-Medicaid Plan 1K–10K 4.5% 1

Medicare-Medicaid Plan 10K–100K 7.2% 7

Medicare-Medicaid Plan 100K+ 7.0% 1

Highest for their sizeⓘ

Plan

Market · band

State

Requests

Band median

Rate

UCare Connect + MedicareUCare

Medicare Advantage · 1K–10K

3,685

10.0%

46.6% +36.6

Prepaid Medical Assistance Program (PMAP)UCare

Medicaid Managed Care · 10K–100K

30,736

12.1%

47.8% +35.7

UCare Minnesota Senior Health Options (MSHO)UCare

Medicare Advantage · 1K–10K

Medicaid Managed Care · 1K–10K

6,578

11.3%

45.2% +33.8

MinnesotaCare (MnCare)UCare

Medicaid Managed Care · 1K–10K

6,208

11.3%

45.1% +33.8

AmeriHealth Caritas Delaware CHIPAmeriHealth Caritas Family of Companies

CHIP Managed Care · 1K–10K

2,764

16.6%

48.4% +31.8

Minnesota Senior Care Plus (MSC+)UCare

Medicaid Managed Care · 1K–10K

1,101

11.3%

41.9% +30.5

Univera Healthcare Medicare D-SNP (HMO)Univera Healthcare

Medicare Advantage · 100–1K

118

9.2%

36.4% +27.3

EssentiaCare PlansUCare

Medicare Advantage · 100–1K

382

9.2%

35.1% +25.9

Ambetter from Superior HealthPlan (29418)Centene

Marketplace QHP · 100K+

218,062

9.8%

32.9% +23.1

Medi-Cal Dental Fee-for-ServiceCalifornia DHCS

Oklahoma Complete Health - SoonerSelectCentene

Medicaid Managed Care · 10K–100K

72,761

12.1%

32.4% +20.3

04 · The appeal gap

Most denials are never tested

Among filings that publish appeal counts (365 of them), 64.0% of standard denials were appealedⓘ, and 3.7% of those appeals overturned the denial. An overturn rate describes the denials someone fought; the denials nobody fought are the larger number, and it is listed here.

5.6M

standard denials in filings that report appeals the filings

3.6M

appeals filed · 64.0% of denials

3.7%

of appeals overturned the denial

2.0M

denials never appealedⓘ

Plan

Organization

Denied

Appeals

Appeal rate

Overturned

Never appealed

Medi-Cal Dental Fee-for-Service Medicaid FFS, CA

Humana H5216 Medicare Advantage

Ohio Medicaid Managed Care - all plans combined Medicaid Managed Care, OH

Ohio Department of Medicaid

California Children's Services (CCS) Medicaid FFS, CA

Virginia Medicaid Fee-for-Service (Cardinal Care FFS) Medicaid FFS, VA

Medicaid Managed Care Medicaid Managed Care, NY

CareSource Ohio Medicaid Medicaid Managed Care, OH

Humana H1036 Medicare Advantage

Ambetter Health Florida / Celtic (49004) Marketplace QHP, FL

Health Net Medi-Cal Medicaid Managed Care, CA

Sunshine Health Medicaid MMA Medicaid Managed Care, FL

Ambetter from Superior HealthPlan (29418) Marketplace QHP, TX

Meridian Illinois Medicaid Medicaid Managed Care, IL

Humana H5619 Medicare Advantage

Contract H3359 Medicare Advantage, NY

Everything on this page is computed from the published counts in the filings; the plan pages show the source document for each figure. Where a plan published a rate without counts it cannot appear here, because a rate nobody can check is not a number of denials.