California Insurance Denial Report

The worst health insurers in California
by claim denial rate

California averages a 15.2% denial rate — 3.9 points below the national average. About 890,000 claims are denied annually.

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15.2%
California avg denial rate
19.1%
National average
890,000
Annual denials in state
>80%
Appeals overturned when filed

Health insurance denials in California

In California, the average health insurance claim denial rate stands at 15.2%, which is notably lower than the national average of 19.1%. This statistic translates to approximately 890,000 annual denials, highlighting a significant issue that affects many residents seeking necessary medical care. Understanding these denial rates is crucial for patients, as it reflects both the challenges they face in accessing healthcare and the importance of being informed about their rights in the insurance process. With a lower denial rate than the national average, Californians may feel a sense of relief, but the reality remains that a substantial number of claims are still denied each year.

Patients in California have the right to appeal denied claims, empowering them to take action when faced with an insurance denial. The California Department of Managed Health Care serves as the regulatory body overseeing health insurance practices in the state. If an internal appeal does not yield a favorable outcome, patients can escalate their cases to this department, ensuring that their concerns are heard. This process not only helps individuals navigate the complexities of the insurance system but also fosters accountability among insurers, encouraging them to reconsider unjust denials.

Worst insurers in California by denial rate

Source: CMS Marketplace Transparency Report 2023. In-network ACA marketplace claims only.

1

Molina Healthcare

22.4% denial rate

Molina denies 22.4% of claims — 3.3 points above the national average. Their appeal overturn rate is 55%.

GLP-1 Medications: 38% deniedSpecialty Medications: 30% deniedMental Health: 25% denied
Full Molina denial report →
2

Oscar Health

34.6% denial rate

Oscar denies 34.6% of claims — 15.5 points above the national average. Their appeal overturn rate is 58%.

GLP-1 Medications: 46% deniedMental Health: 41% deniedSpecialty Medications: 38% denied
Full Oscar denial report →
3

Anthem Blue Cross Blue Shield

18.8% denial rate

Anthem denies 18.8% of claims — 0.3 points below the national average. Their appeal overturn rate is 63%.

GLP-1 Medications: 32% deniedSpecialty Medications: 25% deniedMental Health: 20% denied
Full Anthem denial report →

Your rights as a California insurance patient

California law provides specific protections for patients facing claim denials. Patients have the right to an internal appeal, allowing them to challenge the insurer's decision directly. If the internal appeal does not resolve the issue, they can request an external Independent Medical Review, which offers an impartial evaluation of the claim. The California Department of Managed Health Care oversees these processes, ensuring that patients are treated fairly. Additionally, filing a complaint with this regulatory body is free and can create pressure on insurers to revisit their decisions, ultimately supporting patients in their quest for necessary care.

California Department of Managed Health Care
https://www.dmhc.ca.gov

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How to appeal a denial in California

  1. 1
    Request the denial in writing
    Ask your insurer for the specific clinical criteria and coverage policy they used to deny you. They are legally required to provide it within 30 days.
  2. 2
    File your internal appeal
    Send a written appeal to your insurer within 180 days. Cite your doctor's clinical documentation, relevant medical guidelines, and California insurance law. A well-written appeal citing specific laws wins over 80% of the time.
  3. 3
    Escalate to the state if denied again
    If your internal appeal is denied, file an Independent Medical Review (IMR) with the California Department of Managed Health Care. This is free and decided by independent clinicians. Their decision is often binding.
  4. 4
    Use disputes.health to generate your letter
    Our agents generate a clinic-grade appeal letter in under 15 minutes — citing your state's laws, relevant medical guidelines, and your specific situation. We then submit it to your insurer for you.
How to appeal a denial →GLP-1 denial guide →Mental health denial guide →All public resources →

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