Questions & answers · Health insurance
What percentage of health insurance claims are denied in the US?
Health insuranceDeniedChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: CMS · Marketplace View original ↗
In short
- These sources give no single denial rate.
- CMS posts some data, but only for Marketplace plans.
- You can still appeal: 180 days inside, 4 months outside.
What this means
A single national denial rate is hard to pin down. We will not give you a number we cannot source. The federal government does publish claim and appeal counts. CMS calls it the Transparency in Coverage PUF [1]. It covers insurers that sell on the Exchanges only — not job-based plans, not Medicare, not Medicaid.
Rates differ by insurer, by plan, by year, and by what counts as a "claim." Ask which file and which year back any number you see.
What does not change is what you can do about your own denial. File your internal appeal within 180 days of the notice [2]. If the plan says no again, ask for an external review within 4 months. The insurer must accept that decision [3].
Your next step
If your own claim was denied, file the internal appeal within 180 days of the notice [2]. Then keep the 4-month window in mind for the outside review [3]. If you want the numbers themselves, open the CMS page and download the Transparency in Coverage file [1]. Read its data dictionary before you quote a rate.
Check it yourself
Open the CMS Public Use Files page. Find "Transparency in Coverage PUF" in the list. Then open the HealthCare.gov internal appeals page. Open the external review page too. Read the 180-day line and the 4-month line.
Where this comes from (3)
[1] CMS · Marketplace · checked 2026-11-06
Transparency in Coverage PUF (TC-PUF) – Issuer and plan-level claims, appeals, and active URL data. The PY2027 PUF contains data from PY2025 for issuers participating in the Exchanges in PY2027.
[2] HealthCare.gov · Internal appeals · checked 2026-11-06
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
[3] HealthCare.gov · External review · checked 2026-11-06
You must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied. … An external review either upholds your insurer's decision or decides in your favor. Your insurer is required by law to accept the external reviewer's decision.
How we found this
We matched your question to 3 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
Every answer is checked against the official rule it quotes.
Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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Answer id CQ2124. Spotted an error? Tell us.