Massachusetts Insurance Denial Report

The worst health insurers in Massachusetts
by claim denial rate

Massachusetts averages a 12.3% denial rate — 6.8 points below the national average. About 210,000 claims are denied annually.

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12.3%
Massachusetts avg denial rate
19.1%
National average
210,000
Annual denials in state
>80%
Appeals overturned when filed

Health insurance denials in Massachusetts

In Massachusetts, the average health insurance claim denial rate stands at 12.3%, significantly lower than the national average of 19.1%. This translates to approximately 210,000 annual denials, highlighting a substantial issue that affects many residents. While the lower denial rate is a positive sign, it still represents a considerable number of people facing obstacles in accessing necessary healthcare services. Understanding the denial rate is crucial for patients, as it reflects the challenges they may encounter when seeking coverage for medical treatments and procedures.

Worst insurers in Massachusetts by denial rate

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

1

Aetna (CVS Health)

17.2% denial rate

Aetna denies 17.2% of claims — 1.9 points below the national average. Their appeal overturn rate is 65%.

GLP-1 Medications: 28% deniedSpecialty Medications: 22% deniedMental Health: 18% denied
Full Aetna denial report →
2

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 →
3

UnitedHealthcare

32.5% denial rate

UHC denies 32.5% of claims — 13.4 points above the national average. Their appeal overturn rate is 57%.

Specialty Medications: 43% deniedGLP-1 Medications: 41% deniedMRI / CT Scans: 35% denied
Full UHC denial report →

Your rights as a Massachusetts insurance patient

Massachusetts offers specific protections for patients facing claim denials. Residents have the right to an internal appeal, allowing them to contest the insurer's decision directly. If the internal appeal is unsuccessful, patients can pursue an external Independent Medical Review, providing an unbiased assessment of the claim. The Massachusetts Division of Insurance oversees these processes, ensuring that patients are treated fairly. Filing a complaint with this regulatory body is free and can exert pressure on insurers to reconsider their decisions, empowering patients to advocate for their healthcare needs.

Massachusetts Division of Insurance
https://www.mass.gov/orgs/division-of-insurance

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How to appeal a denial in Massachusetts

  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 Massachusetts 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 Massachusetts Division of Insurance. 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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