02 · Denials
Who says no, and what happens next
494,514 standard requests were denied across the 48 filings in Marketplace QHP that publish counts (of 70), a 10.1% 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.
17
of 44 filings deny expedited requests more often than standard ones
1
publish a standard mean over 7 days the filings
0
publish an expedited mean over 72 hours the filings
19
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 · 64 filings publish one
7
6
20
26
4
1
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 · 66 filings publish one
4
4
15
31
12
0–6
6–12
12–24
24–48
48–72
over 72
hours; the orange bar is past the clock.
Urgent against routine, 44 filings with 100+ expedited requests click a point for the filing
Standard denial rate across, expedited denial rate up, both to 40%. 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.
010%20%30%40% standard denial rate
● 17 deny urgent requests more often
● 27 deny them less often
The widest gaps
Percentage points by which the expedited rate exceeds the standard rate in the same filing.
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
● 62 filings publish both
● 14 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
● 66 filings publish both
● 22 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
Network Health ACA/exchange plans Marketplace QHP
Network Health (Wisconsin)
13.9%
23.9%
4.0 · 1.5 d
48.0 · 36.0 h
+10.0 pts
Ambetter from NH Healthy Families Marketplace QHP
Centene
23.1%
30.9%
2.0 · 0.0 d
24.0 · 0.0 h
+7.8 pts
Highmark QHP (federal Marketplace) - New York Marketplace QHP
Highmark
3.4%
10.3%
0.9 · 0.0 d
12.5 · 0.0 h
+6.9 pts
Ambetter from Absolute Total Care (79222) Marketplace QHP
Centene
21.5%
26.9%
4.0 · 1.0 d
24.0 · 0.0 h
+5.5 pts
Priority Health Qualified Health Plan Marketplace QHP
Priority Health
17.6%
21.4%
1.2 · 1.0 d
11.1 · 1.6 h
+3.9 pts
Ambetter of North Carolina (77264) Marketplace QHP
Centene
20.7%
24.2%
2.0 · 1.0 d
24.0 · 24.0 h
+3.5 pts
University Community Care Plan (Marketplace) Marketplace QHP
Community First Health Plans
2.8%
5.6%
4.0 · 2.0 d
40.1 · 24.0 h
+2.8 pts
Ambetter Health Florida (86382) Marketplace QHP
Centene
18.3%
20.9%
4.0 · 0.0 d
24.0 · 24.0 h
+2.7 pts
Highmark QHP (federal Marketplace) - Pennsylvania Marketplace QHP
Highmark
6.1%
8.4%
0.4 · 0.0 d
11.8 · 0.0 h
+2.3 pts
L.A. Care Medi-Cal Marketplace QHP
L.A. Care Health Plan
1.9%
3.8%
— · —
— · —
+1.9 pts
Rocky Mountain Health Plans - QHP Off-Exchange (Commercial) Marketplace QHP
Rocky Mountain Health Plans
9.1%
10.6%
4.9 · 3.0 d
44.2 · 15.0 h
+1.4 pts
HealthPartners Commercial Wisconsin Federally Facilitated Exchange (on-exchange QHP) plans Marketplace QHP
HealthPartners
13.7%
14.8%
4.0 · 0.0 d
21.7 · 0.7 h
+1.1 pts
Against the clock, and against themselves
Plan
Organization
Standard
Expedited
Std mean · median
Exp mean · median
Flag
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
mean and median three times apart
Kaiser Foundation Health Plan (Hawaii QHP) Marketplace QHP
Kaiser Permanente
—
—
1.4 · 0.2 d
6.0 · 1.0 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
Blue Cross and Blue Shield of Kansas - Qualified Health Plans Marketplace QHP
Blue Cross and Blue Shield of Kansas
—
—
8.0 · 8.0 d
51.1 · 48.0 h
standard mean over 7 days
BCBSNE Qualified Health Plans Marketplace QHP
Blue Cross and Blue Shield of Nebraska
—
—
7.0 · 4.0 d
15.0 · 1.0 h
mean and median three times apart
Sanford Health Plan QHP - South Dakota Marketplace QHP
Sanford Health
—
—
4.2 · 1.0 d
50.4 · 0.0 h
mean and median three times apart
Ambetter from Absolute Total Care (79222) Marketplace QHP
Centene
—
—
4.0 · 1.0 d
24.0 · 0.0 h
mean and median three times apart
Ambetter from Arizona Complete Health (91450) Marketplace QHP
Centene
—
—
4.0 · 1.0 d
48.0 · 24.0 h
mean and median three times apart
HealthPartners Commercial Wisconsin Federally Facilitated Exchange (on-exchange QHP) plans Marketplace QHP
HealthPartners
—
—
4.0 · 0.0 d
21.7 · 0.7 h
mean and median three times apart
Sentara Health Plans - Commercial Marketplace QHP
Sentara Health
—
—
4.0 · 2.0 d
20.1 · 1.0 h
mean and median three times apart
IEHP Covered California Marketplace QHP
Inland Empire Health Plan
—
—
2.6 · 1.0 d
13.4 · 0.5 h
mean and median three times apart
Oscar Health - Ohio (issuer 45845) Marketplace QHP
Oscar Health
—
—
2.4 · 0.5 d
24.0 · 24.0 h
mean and median three times apart
Oscar Health - Tennessee Marketplace QHP
Oscar Health
—
—
2.3 · 0.7 d
21.6 · 21.6 h
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.
Highest rates, organizations with 10,000+ requestsⓘ
Plans with the most denials
Plan
Market
State
Requests
Denied
Rate
Ambetter Health Florida / Celtic (49004)Centene
Marketplace QHP
FL
419,452
88,079
21.0%
Ambetter from Superior HealthPlan (29418)Centene
Marketplace QHP
TX
218,062
71,824
32.9%
L.A. Care Medi-CalL.A. Care Health Plan
Marketplace QHP
CA
2,152,883
40,033
1.9%
Ambetter from Superior HealthPlan (87226)Centene
Marketplace QHP
TX
89,666
29,126
32.5%
Ambetter of TennesseeCentene
Marketplace QHP
TN
104,566
23,800
22.8%
Ambetter from Absolute Total Care (79222)Centene
Marketplace QHP
SC
99,318
21,310
21.5%
Ambetter from Home State Health (99723)Centene
Marketplace QHP
MO
89,747
20,468
22.8%
Ambetter from Magnolia Health (90714)Centene
Marketplace QHP
MS
91,950
19,790
21.5%
Ambetter from Sunflower Health Plan (34368)Centene
Marketplace QHP
KS
64,114
16,362
25.5%
Ambetter from Buckeye Health PlanCentene
Marketplace QHP
OH
52,991
15,037
28.4%
Denial rate by stateⓘ
click a state for its filings≤ 10.7%10.7% – 20.3%20.3% – 22.4%22.4% – 24.2%> 24.2%not published
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, 47 filings click a point for the filing
1001K10K100K1M requests
● Marketplace QHP
Median rate by market and size bandⓘ
Highest for their sizeⓘ
Plan
Market · band
State
Requests
Band median
Rate
Ambetter from Superior HealthPlan (29418)Centene
Marketplace QHP · 100K+
TX
218,062
9.8%
32.9% +23.1
Ambetter Health of DelawareCentene
Marketplace QHP · 1K–10K
DE
2,946
12.2%
27.7% +15.5
Ambetter of TennesseeCentene
Marketplace QHP · 100K+
TN
104,566
9.8%
22.8% +12.9
Ambetter Health Florida / Celtic (49004)Centene
Marketplace QHP · 100K+
FL
419,452
9.8%
21.0% +11.2
Ambetter from Superior HealthPlan (87226)Centene
Marketplace QHP · 10K–100K
TX
89,666
22.0%
32.5% +10.5
Sanford Health Plan QHP - North DakotaSanford Health
Marketplace QHP · 1K–10K
ND
3,646
12.2%
22.4% +10.3
Ambetter of OklahomaCentene
Marketplace QHP · 10K–100K
OK
38,282
22.0%
30.1% +8.1
Ambetter of AlabamaCentene
Marketplace QHP · 10K–100K
AL
38,711
22.0%
28.5% +6.5
Ambetter from Buckeye Health PlanCentene
Marketplace QHP · 10K–100K
OH
52,991
22.0%
28.4% +6.4
Ambetter Health Florida (86382)Centene
Marketplace QHP · 1K–10K
FL
6,402
12.2%
18.3% +6.1
Sanford Health Plan QHP - South DakotaSanford Health
Marketplace QHP · 1K–10K
SD
3,454
12.2%
16.5% +4.4
Ambetter from Arizona Complete Health (91450)Centene
Marketplace QHP · 10K–100K
AZ
54,027
22.0%
26.0% +4.0
04 · The appeal gap
Most denials are never tested
Among filings that publish appeal counts (43 of them), 499.9% of standard denials were appealedⓘ, and 0.7% 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.
485K
standard denials in filings that report appeals the filings
2.4M
appeals filed · 499.9% of denials
0.7%
of appeals overturned the denial
-1,940,184
denials never appealedⓘ
Plan
Organization
Denied
Appeals
Appeal rate
Overturned
Never appealed
Ambetter Health Florida / Celtic (49004) Marketplace QHP, FL
Centene
88,079
3,670
4.2%
58.2%
84,409
Ambetter from Superior HealthPlan (29418) Marketplace QHP, TX
Centene
71,824
3,439
4.8%
61.9%
68,385
Ambetter from Superior HealthPlan (87226) Marketplace QHP, TX
Centene
29,126
1,297
4.5%
60.1%
27,829
Ambetter of Tennessee Marketplace QHP, TN
Centene
23,800
3,238
13.6%
68.5%
20,562
Ambetter from Absolute Total Care (79222) Marketplace QHP, SC
Centene
21,310
1,646
7.7%
56.8%
19,664
Ambetter from Magnolia Health (90714) Marketplace QHP, MS
Centene
19,790
1,120
5.7%
33.8%
18,670
Ambetter from Home State Health (99723) Marketplace QHP, MO
Centene
20,468
2,503
12.2%
57.6%
17,965
Ambetter from Sunflower Health Plan (34368) Marketplace QHP, KS
Centene
16,362
1,702
10.4%
52.4%
14,660
Ambetter from Buckeye Health Plan Marketplace QHP, OH
Centene
15,037
441
2.9%
56.9%
14,596
Ambetter from Arizona Complete Health (91450) Marketplace QHP, AZ
Centene
14,044
378
2.7%
37.3%
13,666
Ambetter Health (Indiana / MHS Indiana marketplace) Marketplace QHP, IN
Centene
13,995
1,884
13.5%
36.3%
12,111
Sentara Health Plans - Commercial Marketplace QHP, VA
Sentara Health
11,838
127
1.1%
44.1%
11,711
Ambetter of Oklahoma Marketplace QHP, OK
Centene
11,527
777
6.7%
29.9%
10,750
Ambetter of Alabama Marketplace QHP, AL
Centene
11,042
903
8.2%
29.2%
10,139
Ambetter of North Carolina (77264) Marketplace QHP, NC
Centene
10,418
1,679
16.1%
51.8%
8,739
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.