Insurance Denial Report

Anthem Blue Cross Blue Shield denies 18.8% of claims.
Here's how patients are fighting back.

Data from the 2023 CMS Marketplace Transparency Report. The national average is 19.1%. Anthem denies claims at 0.3 points below average.

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18.8%
Claims denied
0.3pts
Below national avg
63%
Appeals overturned
14
States they operate in

What Anthem Blue Cross Blue Shield's denial rate means for patients

Anthem Blue Cross Blue Shield has a health insurance claim denial rate of 18.8%, which is slightly below the national average of 19.1%. This means that while some claims may be denied, a significant number of patients still receive the coverage they need after appealing. Understanding this denial rate can help patients navigate their insurance more effectively, ensuring that they are aware of their rights and options when faced with a claim denial.

The encouraging news is that appeals can be highly effective. In fact, 63% of appeals are overturned in favor of the patient. This statistic underscores the importance of not losing hope if your claim is denied. Patients have the right to challenge decisions and seek the care they deserve. With a denial rate lower than the national average, Anthem Blue Cross Blue Shield shows a willingness to reconsider claims when patients advocate for themselves.

What Anthem denies most often

Denial rates by treatment category, compared to the national average (19.1%).

GLP-1 Medications (Ozempic, Wegovy)
vs. ~19% avg
32%
Specialty Medications
vs. ~19% avg
25%
Mental Health
vs. ~19% avg
20%
MRI / CT Scans
vs. ~19% avg
14%

Anthem's most common denial reasons

  1. 1Not medically necessary
  2. 2Lack of prior authorization
  3. 3Formulary exception denied
  4. 4Step therapy not met
  5. 5Benefit limit exceeded

How to appeal a Anthem Blue Cross Blue Shield denial

If you receive a denial from Anthem Blue Cross Blue Shield, it’s essential to act promptly. You typically have 180 days to file an appeal, so gather your documentation quickly. Start by writing to the appeals address provided in your denial letter. Request the clinical criteria used to evaluate your claim, as this information will help you understand their decision. Additionally, consider requesting a peer-to-peer review with their medical director, which can often provide clarity and support for your case. Be sure to include any relevant medical records or letters from your healthcare provider that demonstrate the necessity of the treatment.

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Frequently asked questions about Anthem Blue Cross Blue Shield denials

How long do appeals take with Anthem Blue Cross Blue Shield?
The duration of an appeal with Anthem Blue Cross Blue Shield can vary, but typically, you can expect a decision within 30 to 60 days after your appeal is submitted. However, complex cases may take longer. It's important to stay in communication with Anthem for updates on your appeal status.
What documentation helps most when appealing a denial?
When appealing a denial, the most helpful documentation includes a detailed letter explaining why the treatment is necessary, medical records that support your case, and any relevant clinical guidelines. Additionally, letters from your healthcare provider can strengthen your appeal by providing professional insights into your medical needs.
What should I do if my first appeal is denied?
If your first appeal is denied, don’t be discouraged. Review the denial letter carefully to understand the reasons for the denial. You can submit a second appeal, addressing the specific issues raised. Consider gathering more supporting documentation or seeking assistance from your healthcare provider to bolster your case.
Do I need an attorney to appeal a denial from Anthem Blue Cross Blue Shield?
While you are not required to have an attorney to appeal a denial, having legal assistance can be beneficial, especially in complex cases. An attorney experienced in insurance claims can help you navigate the appeals process, understand your rights, and ensure that all necessary documentation is submitted correctly.
GLP-1 appeal guide →MRI denial guide →How to appeal guide →Full resource center →

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