Claims Denials and Appeals in ACA Marketplace Plans

The CMS transparency data public use files display data reported by issuers that participate in the ACA individual market in healthcare.gov states. The data posted by CMS includes issuers of major medical qualified health plans as well as those that only offer stand-alone dental plans (SADPs). The data posted by CMS include instances of missing data and suppressed data, as well as some data that appear to be invalid (for example, an issuer with more denials than claims).

For this analysis, we condensed the transparency public use files into working data files, posted with this brief, that separate issuers with complete data from those with missing or invalid data. Issuers were excluded for missing data if “Claims Received,” “Claims Denied,” or “Enrollment Data” is missing (including cases where these fields show “*” or “N/A”). Issuers were excluded if “Claims Received” or “Enrollment Data” is less than 1000 (including instances of suppressed data).

There is a data dictionary on the first sheet of each of the working data files posted with this brief.

Issue Brief

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