20% Of In-Network Exchange Plan Medical Necessity Denials Were For Behavioral Health

About 20% of medical necessity denials of claims submitted to HealthCare.gov plans in 2020 were for in-network behavioral health services. That year, the HealthCare.gov plans received 230.9 million in-network claims, and of those, 18.3% (42.3 million claims) were denied. About 10% of denials of in-network claims were for services that lacked prior-authorization or referral, 16% were for excluded services, 2% for medical necessity reasons, and 72% for all other reasons. Of those in-network denials, about 0.4% were behavioral health claims denied for medical necessity.

An analysis of insurer denial . . .