New Jersey Insurance Denial Report

The worst health insurers in New Jersey
by claim denial rate

New Jersey averages a 16.8% denial rate — 2.3 points below the national average. About 380,000 claims are denied annually.

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16.8%
New Jersey avg denial rate
19.1%
National average
380,000
Annual denials in state
>80%
Appeals overturned when filed

Health insurance denials in New Jersey

In New Jersey, the health insurance claim denial rate stands at 16.8%, which is notably lower than the national average of 19.1%. This translates to approximately 380,000 annual denials, highlighting a significant issue that affects many residents seeking necessary medical care. A denial can create barriers to accessing treatments and services, leaving patients feeling frustrated and overwhelmed. Understanding this rate is crucial for New Jersey residents as it underscores the importance of being informed about their rights and options when faced with a denial.

Patients in New Jersey have the right to appeal any denied claims, empowering them to challenge decisions made by their insurance providers. The New Jersey Department of Banking & Insurance serves as the regulatory body overseeing these matters, ensuring that residents have access to fair processes. If an internal appeal does not yield a satisfactory outcome, patients can escalate their case to the department, which can help facilitate a resolution. Knowing these rights can provide patients with the confidence to advocate for their healthcare needs effectively.

Worst insurers in New Jersey by denial rate

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

1

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 →
2

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 →
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 New Jersey insurance patient

New Jersey offers specific patient protections that empower individuals facing claim denials. Patients have the right to an internal appeal, allowing them to contest the insurer's decision directly. If the internal appeal does not resolve the issue, they can request an external Independent Medical Review, where an unbiased third party evaluates the claim. The New Jersey Department of Banking & Insurance oversees these processes, ensuring compliance and fairness. Additionally, filing a complaint with the department is free and can apply pressure on insurers to reconsider their decisions, further protecting patient rights.

New Jersey Department of Banking & Insurance
https://www.nj.gov/dobi

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How to appeal a denial in New Jersey

  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 New Jersey 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 New Jersey Department of Banking & 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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