What is the average health insurance denial rate in Texas?

Health insurers in Texas deny approximately 22.3% of ACA marketplace claims, which is 3.2 points above the national average of 19.1%.

How do I appeal a denied insurance claim in Texas?

File a written internal appeal with your insurer within 180 days of the denial. If denied again, escalate to an Independent Medical Review (IMR) with the Texas Department of Insurance. IMRs are free, decided by independent clinicians, and have high success rates.

Which insurance company denies the most claims in Texas?

Based on CMS Marketplace Transparency data, the insurers with the highest denial rates in Texas are Cigna Healthcare, Blue Cross Blue Shield of Texas, Ambetter from Centene. See each insurer's full denial report for category-level breakdowns.

What are my rights if my insurance claim is denied in Texas?

You have the right to a full written explanation of the denial, an internal appeal, and an external Independent Medical Review with the Texas Department of Insurance. Federal law requires insurers to respond to standard appeals within 30 days and urgent appeals within 72 hours.

Texas Insurance Denial Report

The worst health insurers in Texas
by claim denial rate

Texas averages a 22.3% denial rate — 3.2 points above the national average. About 1,450,000 claims are denied annually.

Fight My Denial in Texas →

22.3%

Texas avg denial rate

19.1%

National average

1,450,000

Annual denials in state

>80%

Appeals overturned when filed

Health insurance denials in Texas

In Texas, the average health insurance claim denial rate stands at 22.3%, significantly higher than the national average of 19.1%. This statistic translates to approximately 1,450,000 annual denials, highlighting a critical issue that affects many residents seeking necessary medical care. The elevated denial rate indicates that a substantial number of Texans may face challenges in accessing the healthcare services they need, making it essential for patients to understand their rights and options when dealing with insurance claims.

Fortunately, patients in Texas have the right to appeal denied claims. This process allows individuals to contest decisions made by their insurance providers. Should internal appeals fail, patients can escalate their cases to the Texas Department of Insurance, the regulatory body overseeing insurance practices in the state. By knowing their rights and the avenues available for appeal, Texans can take proactive steps to ensure they receive the healthcare coverage they deserve.

Worst insurers in Texas by denial rate

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

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 →

Blue Cross Blue Shield of Texas

20.1% denial rate

BCBS Texas denies 20.1% of claims — 1.0 points above the national average. Their appeal overturn rate is 60%.

GLP-1 Medications: 35% deniedSpecialty Medications: 27% deniedMental Health: 22% denied

Full BCBS Texas denial report →

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 Texas insurance patient

In Texas, patients benefit from specific protections regarding health insurance claims. They have the right to an internal appeal if their claim is denied, as well as the option for an external Independent Medical Review if the internal appeal does not yield a favorable outcome. The Texas Department of Insurance serves as the regulatory body that oversees these processes. Filing a complaint with the department is free and can create pressure on insurers to reconsider their denial decisions, empowering patients to advocate for their healthcare needs.

Texas Department of Insurance
https://www.tdi.texas.gov

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How to appeal a denial in Texas

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
File your internal appeal
Send a written appeal to your insurer within 180 days. Cite your doctor's clinical documentation, relevant medical guidelines, and Texas insurance law. A well-written appeal citing specific laws wins over 80% of the time.
3
Escalate to the state if denied again
If your internal appeal is denied, file an Independent Medical Review (IMR) with the Texas Department of Insurance. This is free and decided by independent clinicians. Their decision is often binding.
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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The worst health insurers in Texasby claim denial rate