North Carolina Insurance Denial Report

The worst health insurers in North Carolina
by claim denial rate

North Carolina averages a 22.6% denial rate — 3.5 points above the national average. About 530,000 claims are denied annually.

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22.6%
North Carolina avg denial rate
19.1%
National average
530,000
Annual denials in state
>80%
Appeals overturned when filed

Health insurance denials in North Carolina

In North Carolina, health insurance claim denials are a significant issue, with an average denial rate of 22.6%, notably higher than the national average of 19.1%. This translates to approximately 530,000 denials each year, affecting countless patients who rely on their insurance to cover necessary medical expenses. Understanding this statistic is crucial for North Carolinians, as it highlights the importance of being proactive in managing health insurance claims and advocating for one's health needs. The higher denial rate underscores the need for patients to be informed and prepared to challenge these decisions when they arise.

Fortunately, patients in North Carolina have the right to appeal denied claims. If a claim is denied, individuals can initiate an internal appeal with their insurance company, providing them an opportunity to review the decision. Additionally, if the internal appeal is unsuccessful, patients can escalate their case to the North Carolina Department of Insurance, the regulatory body overseeing insurance practices in the state. This process empowers patients to advocate for their rights and ensures that they have recourse when faced with unjust denials.

Worst insurers in North Carolina 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

Cigna Healthcare

33.1% denial rate

Cigna denies 33.1% of claims — 14.0 points above the national average. Their appeal overturn rate is 61%.

GLP-1 Medications: 44% deniedSpecialty Medications: 40% deniedMental Health: 37% denied
Full Cigna denial report →
3

Ambetter from Centene

21.3% denial rate

Ambetter denies 21.3% of claims — 2.2 points above the national average. Their appeal overturn rate is 53%.

GLP-1 Medications: 36% deniedSpecialty Medications: 28% deniedMental Health: 24% denied
Full Ambetter denial report →

Your rights as a North Carolina insurance patient

North Carolina offers specific patient protections that empower individuals facing claim denials. Patients have the right to an internal appeal process, allowing them to contest denied claims directly with their insurance provider. If the internal appeal does not yield a favorable outcome, they can request an external Independent Medical Review, providing an unbiased evaluation of the claim. The North Carolina Department of Insurance serves as the regulatory body overseeing these processes, and patients can file complaints at no cost. This ability to escalate issues can create pressure on insurers to reconsider their decisions, ultimately supporting patients in obtaining the care they need.

North Carolina Department of Insurance
https://www.ncdoi.gov

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How to appeal a denial in North Carolina

  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 North Carolina 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 North Carolina Department 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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