ACA Marketplace Plans Deny Over 16% of In-Network Claims in 2021
February
17
About 16.6% of in-network claims were denied by non-group qualified health plans (QHPs) offered on HealthCare.gov in 2021, down from 18.3% in 2020, according to a recent Kaiser Family Foundation analysis. Among the 162 issuers in HealthCare.gov states with complete data on claims received and denied, 65 of them had a denial rate between 10% and 19%. Only 17 issuers had a denial rate over 30%, compared with 28 in 2020. The majority of denials (76.5%) were classified as “all other reasons,” while 8% were for services that lacked a prior authorization or referral. Of the more than 48 million denied claims in 2021, marketplace enrollees appealed 90,599 claims — a 0.2% appeal rate — and insurers upheld 59% of denials that were appealed.
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