Insurance Denial Report

Health First Health Plans denies 27.8% of claims.
Here's how patients are fighting back.

Data from the 2023 CMS Marketplace Transparency Report. The national average is 19.1%. Health First denies claims at 8.7 points above average.

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27.8%
Claims denied
8.7pts
Above national avg
64%
Appeals overturned
1
States they operate in

What Health First Health Plans's denial rate means for patients

Health First Health Plans has a denial rate of 27.8%, which is significantly higher than the national average of 19.1%. This means that nearly one in three claims submitted to Health First are denied, leaving patients feeling frustrated and uncertain about their coverage. Such high denial rates can impact access to necessary treatments and medications, particularly for those who rely on health insurance to manage chronic conditions or acute health issues.

The good news is that patients have the right to appeal these denials, and many do find success. In fact, 64% of appeals against Health First's decisions are overturned in favor of the patient. This highlights the importance of understanding your rights as a policyholder and the appeal process, especially when facing a denial that could affect your health and well-being.

What Health First denies most often

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

GLP-1 Medications (Ozempic, Wegovy)
vs. ~19% avg
48%
Specialty Medications
vs. ~19% avg
35%
Mental Health
vs. ~19% avg
30%
MRI / CT Scans
vs. ~19% avg
22%

Health First's most common denial reasons

  1. 1Not medically necessary
  2. 2Lack of clinical documentation
  3. 3Step therapy not completed
  4. 4Prior authorization required
  5. 5Benefit not included in plan

How to appeal a Health First Health Plans denial

To appeal a denial from Health First Health Plans, start by gathering all relevant documentation, including the denial letter and any medical records that support your case. Send your appeal to the address provided in the denial notice within the typical 180-day deadline. It's crucial to request the clinical criteria used for the denial, as this will help you understand their reasoning. Additionally, consider requesting a peer-to-peer review with their medical director to discuss your case directly, which can strengthen your appeal.

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Frequently asked questions about Health First Health Plans denials

How long do appeals take with Health First Health Plans?
Appeals with Health First Health Plans typically take about 30 days to process. However, if additional information is required, this timeline may extend. It's important to submit a complete appeal to avoid delays.
What documentation helps most in an appeal?
The most helpful documentation for an appeal includes the original denial letter, detailed medical records, letters from your healthcare provider explaining the necessity of the treatment, and any relevant clinical guidelines that support your case.
What should I do if my first appeal is denied?
If your first appeal is denied, don't be discouraged. You can request a second review, often called a 'level two appeal.' Ensure you address any reasons given for the denial and provide additional documentation or clarification to strengthen your case.
Do I need an attorney to appeal a denial?
While you can certainly seek legal assistance for complicated cases, many patients successfully navigate the appeal process on their own. Understanding your policy and the reasons for denial can empower you to make a strong case without legal representation.
GLP-1 appeal guide →MRI denial guide →How to appeal guide →Full resource center →

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