Climbing the Ladder of Insurance Denials
We find that, across HealthCare.gov insurers with complete data, nearly 17% of in-network claims were denied in 2021. Insurer denial rates varied widely around this average, ranging from 2% to 49%. CMS requires insurers to report the reasons for claims denials at the plan level. 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. Most plan-reported denials (77%) were classified as ‘all other reasons.’
What’s a Claim File? Why Should I Request One?
A claim file is a collection of the information your insurer used to decide whether it would pay for your medical treatment or services. Most people in the U.S. facing a denial have the right to request their claim file from their insurer. It can include internal correspondence, recordings of phone calls, case notes, medical records and other relevant information.
Information in your claim file can be critical when appealing denials. Some patients told us they received case notes showing that their insurer’s decision was the outcome of cost-cutting programs. Others have gotten denials overturned by obtaining recordings of phone calls where company staff introduced errors into their cases.
How This Works
Answer a few questions to generate a PDF of your claim file request letter.
Mail, fax or upload the completed letter to your health insurer.
Your claim file request should be fulfilled within 30 days.
If you agree to be contacted, we’ll email you later to see if you’ve received your file.
By law, health insurers’ responses should be timely and the records provided by the company should explain why they denied your claim or prior authorization request. However, ProPublica has found that some insurers don’t respond to claim file requests, or they do respond but send inaccurate or incomplete information. If this happens to you, see “I submitted my request but am having trouble getting my claim file.
What can I do now?”
You Have a Right to Know Why a Health Insurer Denied Your Claim. Some Insurers Still Won’t Tell You.
Federal regulations require insurers to promptly hand over records to patients facing claim denials. Some insurers only turned over their files after ProPublica reached out.
How hard can it get? Some insurers go the distance thinking the patient will give up trying to fight their denial of service.
Insurers Asking for Unnecessary Subpoenas or Court Orders
Cigna and Anthem told members that they would need to obtain a court order or subpoena to access their claim file records.
“This is completely unheard of,” said Wells Wilkinson, a senior attorney with the nonprofit legal group Public Health Advocates which regularly files these requests. “It also sounds completely illegal. The consumer has the right to any information used by the health plan in the context of the denial.”
On July 12, Lisa Kays, a Maryland resident, asked Cigna for phone call records related to its decision to deny coverage for her 4-year-old son’s speech therapy. “We couldn’t afford to just give up,” Kays said.
In September, Cigna sent her a letter saying she would need to submit a subpoena to get any transcripts or recordings.
After ProPublica inquired, the company sent Kays partial transcripts of the calls. It also reimbursed her for some of the previously denied coverage. She is still waiting for the recordings.
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