![]() Data on the number of claims that are denied.Under the ACA, required reporting fields for transparency-in-coverage data include: Transparency data also are not used in oversight nor to develop other tools or indicators to help consumers see and compare differences across plans. Data to answer these questions are not collected and data that are collected are not audited, for example, to ensure issuers report data consistently. Yet, the federal government’s broad authority to require transparency data reporting has not been fully implemented. It could also make more transparent trends in the incidence and handling of claims for surprise medical bills, now protected under the No Surprises Act. For example, transparency data could be helpful in oversight of compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA), revealing how or whether claims denial rates differ for behavioral health vs other services. Data are to inform regulators and consumers about how health plans work in practice. The Affordable Care Act (ACA) requires transparency data reporting by all non-grandfathered employer-sponsored health plans and by non-group plans sold on and off the marketplace. ![]() In 2021, consumers appealed less than two-tenths of 1% of denied in-network claims, and insurers upheld most (59%) denials on appeal. 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. 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. ![]()
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