---
title: "Avera SD appeal form and deadline"
url: "https://denialfacts.com/insurers/avera-health-plans-inc--sd"
publisher: "Axion Labs — Denial Facts"
checked: "2026-11-04"
dataset_fixity: "sha256-cda2f9b89c8dde2a74989a35dbe7c0d08ff35dac5456484dc1c03c1b181a67b6"
---

# Avera denied your claim in South Dakota. Here is your deadline.

Denied by Avera in South Dakota? Your two federal appeal deadlines dated from your notice, a free letter, and its 3.5% denial rate in the federal file.

## Figures

| Figure | Value |
| --- | --- |
| In-network denial rate | 3.5% |
| Claims denied | 17,773 |
| Plans in South Dakota | 30 |
| Internal appeals filed | 72 |
| Internal overturn rate | 69.44% |
| In-network claims received | 504,170 |
| External reviews filed | 0 |
| External overturn rate | not reported |
| National denial rate | 15.7% |

## External-review route

**State-run process.** South Dakota runs its own external review process meeting the federal standards, so an independent review there is handled through the state program rather than the federal one. This route is the one for insured plans, Marketplace, individual, and employer plans where an insurance company carries the risk. If your coverage is through a job and the employer pays the claims itself (a self-funded or self-insured plan, which is 63% of covered workers), the state process does not apply to you whatever your state operates, and your external review goes through the federal process instead. Your denial letter names your route; if it does not, ask your plan in writing whether the plan is self-funded.

## Denials by reason

| Reason | Claims | Share of this insurer's categorized denials |
| --- | --- | --- |
| Administrative reason | 3,391 | 52.6% |
| Service excluded from the plan | 1,636 | 25.4% |
| Provider out of network | 1,361 | 21.1% |
| Other reasons | 43 | 0.7% |
| Referral required | 17 | 0.3% |

## Avera in South Dakota, at the top of the page

South Dakota

Your two dates, free

Date on your denial notice

Who pays your claims?

A job, an insurance company pays the claims

A job, my employer pays the claims itself (self-funded)

A job, I do not know which

Marketplace / individual plan I bought myself

Medicare, Medicaid, TRICARE, VA or IHS

Which state?

The reason your letter gives

I'm not sure, I'll paste the sentence later

Not medically necessary
Provider out of network
Service excluded from the plan
Experimental or investigational
Referral required
Benefit limit reached
Member not covered
Administrative reason
Other reasons

Show my two dates, free

Put in the date on your Avera Health Plans, Inc. notice and get both federal deadlines as calendar dates.

Free, for an Avera Health Plans, Inc. denial in South Dakota, and it runs entirely in your browser. The date, the plan type and the state you pick are never sent to us and never stored.

Avera Health Plans, Inc. denied 17,773 of 504,170 in-network claims in South Dakota; every one of those denials had these same two dates on it. Across South Dakota as a whole the insurers in this file denied 5.9% of in-network claims, 95,138 of them, and 272 were appealed.

Or let the [$29 Appeal Kit](/appeal-kit) date each step and write the claim-file and external-review requests.

Avera Health Plans, Inc. denied 3.5% of in-network claims in South Dakota, 17,773 claims out of 504,170.

By [Axion Labs](/about) · August 19, 2026, updated November 4, 2026

Further down this page, after the free steps: the paid next step .

Insurance got denied, what to do next?

We hear this most. [r/HealthInsurance, thread title](https://www.reddit.com/r/HealthInsurance/comments/1rdxwvi/insurance_got_denied_what_to_do_next/) , read September 3, 2026.

The number nobody else publishes. Not one of the 17,773 denials Avera Health Plans, Inc. issued in South Dakota reached the independent review its own staff do not decide, an explicit zero in this insurer's own filed row, not an absence. The stage was there the whole time and it binds the plan. Nationally 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) of the reviews that got there were overturned.

Those 17,773 denials are 18.7% of every in-network denial recorded in South Dakota in this release, which makes Avera Health Plans, Inc. the 3rd largest source of denials of the 3 insurers reporting there. Spread across its 30 plans in the state that is about 592 denials per plan. 72 internal appeals were filed against those 17,773 denials. Every one of those denials carried the same two dates the tool at the top of this page works out.

The clock your letter has to describe, in actual dates

Two dates matter more than anything else on this page, and they run the same in South Dakota as everywhere else. You have 180 days from the date on your denial notice to file the internal appeal, and then 4 months from the final internal denial to ask for an independent external review. If waiting would seriously jeopardize your health you can ask for both to be expedited, decided in about 72 hours . Both timeframes are federal, not your insurer's choice, [29 CFR 2560.503-1](https://www.ecfr.gov/current/title-29/section-2560.503-1) ( [PDF](https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol9/pdf/CFR-2024-title29-vol9-sec2560-503-1.pdf) ) and [45 CFR 147.136](https://www.ecfr.gov/current/title-45/section-147.136) ( [PDF](https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/pdf/CFR-2024-title45-vol2-sec147-136.pdf) ), in plain English at [HealthCare.gov](https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/) , and your own denial letter states the ones that govern your plan. The PDFs are the same sections on govinfo.gov, which serves them without a challenge page, so an automated reader can check these two dates as easily as you can.

Data verified November 4, 2026 · CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain

You are not alone, and here is the measured version of that sentence: 17,773 in-network claims were denied by Avera Health Plans, Inc. in South Dakota in a single plan year. A denial rate is a fact about an insurer's book of business. It is not a judgment about you, and it is not the last word on your claim.

- Of the 3 insurers reporting a denial rate in South Dakota, Avera Health Plans, Inc. is the second highest at 3.5%. The highest in the state is 15.4% and the lowest is 2.5%.

- That is 12.2 percentage points below the 15.7% national average across this dataset, and 2.4 points below the South Dakota average of 5.9%.

- Behind the percentage: 504,170 in-network claims were processed under 30 plans in South Dakota, and 17,773 of them came back denied.

- For every 10,000 claims Avera Health Plans, Inc. denied, about 41 came back as an internal appeal. The other 9,959 stopped at the letter.

- Of the internal appeals it did receive, Avera Health Plans, Inc. overturned 69.44% , 50 claims that started life as a no.

- Not one of those denials reached independent external review, the stage whose decision the plan is required by law to accept, and where nationally 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) are overturned.

- Its most-recorded denial reason is administrative reason at 52.6% of its categorized denials, against 17.2% nationally, a heavier share than the country as a whole. That is the denial mix, not an outcome rate.

- Avera Health Plans, Inc. accounts for 18.7% of every in-network claim denied in South Dakota in this file.

- By raw volume it is the 121th largest source of denials among the 135 insurer-state records in the file that report one.

- After that, its second-most-recorded reason is [service excluded from the plan](/denial-reasons/service-excluded) , 1,636 claims, 25.4% of its categorized denials.

- Third on its own list is [provider out of network](/denial-reasons/out-of-network) , 1,361 claims, 21.1% of what Avera Health Plans, Inc. categorized in South Dakota. Between them the top three account for 99.1% of its categorized denials.

- Where Avera Health Plans, Inc. differs most from the national mix is [administrative reason](/denial-reasons/administrative) : 52.6% of its categorized denials in South Dakota against 17.2% across the file.

- Read the other way round: 486,397 of those 504,170 in-network claims were paid, 96.5% of everything Avera Health Plans, Inc. processed in South Dakota.

- Spread across the 30 plans it reports in South Dakota, that is about 592 denied claims per plan, on about 16,806 claims processed per plan.

- Its reason columns add up to 6,448 categorized rows against 17,773 denials, 36.3% of them, and every reason share on this page is a share of that first figure rather than of the second.

- Its smallest recorded category in South Dakota is [referral required](/denial-reasons/referral-required) , 17 claims, 0.3% of what Avera Health Plans, Inc. categorized there.

- Against the file as a whole, this one record is 0% of the 83,907,852 in-network claim denials reported by every issuer in it.

What to do tonight

- Find the reason code on your denial letter. The reason Avera Health Plans, Inc. records most often in South Dakota is administrative reason , but yours may be one of the other 8, copy the exact wording and code off your own letter tonight, because that sentence is what your appeal has to answer.

- Ask Avera Health Plans, Inc. in South Dakota for the clinical criteria they judged you against. Under [29 CFR 2560.503-1](https://www.ecfr.gov/current/title-29/section-2560.503-1) they have to hand you the claim file and the policy they applied, free, on request, and you cannot argue with a checklist you have never read.

- Put both deadlines on your calendar before you go to bed. 180 days from the date on the letter for the internal appeal, 4 months from the final internal denial for external review. The free calculator on this page turns your date into the two calendar dates in about ten seconds. Avera Health Plans, Inc. overturned 69.44% of the internal appeals it did receive, 50 claims, so the stage you are about to start is not decorative.

None of those three steps costs anything. Anyone charging you to do them is selling you something you can do yourself in twenty minutes.

3.5%

In-network denial rate

17,773

Claims denied

30

Plans in South Dakota

72

Internal appeals filed

69.44%

Internal overturn rate

## How that compares

| Denial rate | Rate | Difference |
| --- | --- | --- |
| Avera Health Plans, Inc. | 3.5% | , |
| South Dakota average | 5.9% | -2.4 pts |
| National average (this dataset) | 15.7% | -12.2 pts |

Avera Health Plans, Inc. sits at or below the national average across this dataset. A denial rate is a property of the insurer's book of business, coding practice, plan design, the population it covers, not evidence about the merits of any one claim, including yours.

## What happened to appeals

| Stage | Filed | Overturned |
| --- | --- | --- |
| Internal appeal (to Avera Health Plans, Inc.) | 72 | 69.44% |
| External review (independent) | 0 | not reported |

Read that again: Avera Health Plans, Inc. denied 17,773 claims in South Dakota, and not one went to independent external review. External review is free to you and the insurer must follow the decision.

## The gap nobody escalated

17,773 claims denied. 72 internal appeals filed. None reached independent external review. Nationally 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) of external reviews are overturned and the decision binds the plan.

That is arithmetic from the reported figures, not a prediction: nobody can say what those specific denials would have done at review, because they never got there. What the numbers do establish is that the binding stage was almost entirely unused here.

What that record means for your own Avera Health Plans, Inc. letter, and by when. Avera Health Plans, Inc. overturned 69.44% of the 72 internal appeals its South Dakota members filed against 17,773 denials, and not one of those South Dakota denials went on to the independent stage whose decision binds the plan, Avera Health Plans, Inc.'s own rows in the plan-year 2027 release of the CMS Transparency in Coverage file, read November 4, 2026 ( [data.healthcare.gov](https://data.healthcare.gov/) ). Whichever way that lands, nobody files the appeal for you, and the filing runs on a clock set by which plan you hold: an employer or Marketplace plan gives you at least 180 days from the denial notice to file the internal appeal ( [29 CFR 2560.503-1(h)(3)(i)](https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol9/pdf/CFR-2024-title29-vol9-sec2560-503-1.pdf) , carried onto individual-market coverage by [45 CFR 147.136(b)(3)(i)](https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/pdf/CFR-2024-title45-vol2-sec147-136.pdf) ), while Medicare Advantage gives you 65 calendar days from the date of its notice ( [CMS](https://www.cms.gov/medicare/appeals-grievances/managed-care/reconsideration-advantage-health-plan-part-c) , [42 CFR 422.582(b)](https://www.ecfr.gov/current/title-42/section-422.582) ) and Medicaid managed care 60 calendar days from the date on the notice ( [42 CFR 438.402(c)(2)(ii)](https://www.ecfr.gov/current/title-42/section-438.402) ), both stages free, and the three steps above are the whole of what to do tonight, so take the date printed on your Avera Health Plans, Inc. notice and file well inside whichever of those windows is yours. The free steps are above; the [$29 kit](/appeal-kit) is the same clock with the letters pre-filled for Avera Health Plans, Inc. in South Dakota. One payment. No subscription. No cut of your claim.

## Avera Health Plans, Inc. inside South Dakota

Your denial did not happen in a national average. It happened in a state market, alongside 2 other insurers reporting into the same federal file, and these are that market's own figures.

- Across the whole of South Dakota, the 3 insurers reporting in this file processed 1,615,279 in-network claims and denied 95,138 of them, a state denial rate of 5.9%. Avera Health Plans, Inc. is one of those 3.

- That puts South Dakota 29th of 29 states by denial rate, 9.8 points below the 15.7% national average, before you get to what Avera Health Plans, Inc. did inside it.

- South Dakota recorded 272 internal appeals against those denials: one appeal for every 350 claims the state's insurers refused. Avera Health Plans, Inc.'s own ratio is one for every 247.

- Not one denial in South Dakota reached independent external review in the reported year, not Avera Health Plans, Inc.'s and not any other insurer's in the state. That is the stage whose decision the plan is required by law to accept.

- The reason South Dakota's insurers record most often is [other reasons](/denial-reasons/other) , 52,665 claims, 47.9% of the state's categorized denials. Avera Health Plans, Inc. records administrative reason most often instead, which is the argument your letter will need to answer.

- The other insurers a South Dakota reader could have bought from run from 15.4% ( [Wellmark of South Dakota](/insurers/wellmark-of-south-dakota--sd) ) to 2.5% ( [Sanford Health Plan](/insurers/sanford-health-plan--sd) ). Avera Health Plans, Inc. at 3.5% sits between the two.

- Put the two together and Avera Health Plans, Inc. is responsible for 18.7% of every in-network claim denied in South Dakota in this release, from 31.2% of the claims the state's insurers processed.

- Every South Dakota figure in this section is that state's own row in the same federal file Avera Health Plans, Inc.'s numbers above come from, [CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain](https://data.healthcare.gov/) , and the full South Dakota page is free at [/states/south-dakota](/states/south-dakota) .

## What Avera Health Plans, Inc. denies most

The most common denial reason recorded for Avera Health Plans, Inc. plans in South Dakota is administrative reason . [How that denial is beaten →](/denial-reasons/administrative)

| Denial reason | Claims | Share | National share |
| --- | --- | --- | --- |
| Administrative reason | 3,391 | 52.6% | 17.2% |
| Service excluded from the plan | 1,636 | 25.4% | 13.4% |
| Provider out of network | 1,361 | 21.1% | 9% |
| Other reasons | 43 | 0.7% | 32.4% |
| Referral required | 17 | 0.3% | 9.6% |

The last column is each reason's share of all categorized denials nationally, so you can see where Avera Health Plans, Inc.'s mix in South Dakota differs from everyone else's. This is denial mix , not overturn rate by reason , the federal file does not report appeal outcomes broken down by denial reason, and we do not imply otherwise.

Work out your two deadlines

Put the date from your notice in and get the two calendar dates, with the days remaining.

Date on your denial notice

Which denial is this?

First denial (I have not appealed yet)

Final internal denial (my appeal was refused)

Show my deadlines

Runs entirely in your browser, the date you type is never sent to us and never stored. [Open the full calculator →](/appeal-deadline-calculator)

Or let the [$29 Appeal Kit](/appeal-kit) date each step and write the claim-file and external-review requests.

The three steps at the top of this page are the whole of what you have to do tonight. The longer
version, what the internal appeal has to contain, how the independent stage works, and how to ask
for expedited handling when waiting would seriously jeopardize your health, is
[published free here](/how-to-appeal) . For what it is worth on this page specifically: Avera Health Plans, Inc. overturned 69.44% of the internal appeals it received.

## Questions

##### Is Avera Health Plans, Inc.'s denial rate in South Dakota high?

3.5% against a national average of 15.7% across the plans in this dataset. It is at or below average. A denial rate describes the insurer, not the merits of your claim.

##### How many people appealed an Avera Health Plans, Inc. denial in South Dakota, and how many won?

72 internal appeals were filed against 17,773 denials, and 69.44% of them were overturned (50 claims). Not one went on to independent external review, the stage whose decision is binding on the plan.

##### How does Avera Health Plans, Inc. compare with other insurers in South Dakota?

Of the 3 insurers in South Dakota with a reported denial rate, Avera Health Plans, Inc. ranks 2 highest at 3.5%. The highest in South Dakota is Wellmark of South Dakota at 15.4%; the lowest is Sanford Health Plan at 2.5%.

##### What does Avera Health Plans, Inc. deny most often in South Dakota?

Administrative reason, 3,391 claims, 52.6% of this issuer's categorized denials, against 17.2% nationally. This is the denial-reason mix; the federal file does not report overturn rates by reason.

##### How long do I have to appeal an Avera Health Plans, Inc. denial in South Dakota?

Generally 180 days from the date on the denial notice to file the internal appeal, then generally four months from the final internal denial to request independent external review. Expedited review, decided in about 72 hours, is available where delay would seriously jeopardize your health. Those timeframes are federal, so they are identical for every insurer reporting in South Dakota, Avera Health Plans, Inc. included, what varies by state is who runs the independent review at the end. Your own denial letter states the deadlines that govern your plan; that letter is the authority.

##### Does appealing an Avera Health Plans, Inc. denial in South Dakota cost anything?

The internal appeal to Avera Health Plans, Inc. is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25 per review. Nobody in South Dakota can be charged more than that to file one.

##### Can Avera Health Plans, Inc. ignore an external review decision in South Dakota?

No, and that is the whole point of the stage. External review decisions are binding on the plan by law, which is what makes the zero external reviews recorded against 17,773 Avera Health Plans, Inc. denials in South Dakota the striking number on this page.

The line on this page we would read twice is the one that says not one of Avera Health Plans, Inc.'s 17,773 denials in South Dakota reached independent review. We are not going to tell you that you will win. This page prints the insurer's own reported numbers whichever way they fall. If what it says does not match the letter in your hand, write to us and we will correct the page.

Axion Labs · hello@getaxionlabs.com

[Get my Appeal Kit, $29](/appeal-kit)
Everything you need for your Avera Health Plans, Inc. appeal in South Dakota: your two deadlines, the argument that fits your denial reason, the letters, a brief for your doctor on what the reviewer checks, and the external review request. One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com.

Where these numbers come from The Avera Health Plans, Inc. figures on this page, the 3.5% denial rate, the 17,773 denials and the 0 external reviews, are this issuer’s own reported rows in that file.

Counts: [CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain](https://data.healthcare.gov/) . Rights and timeframes: [29 CFR 2560.503-1](https://www.ecfr.gov/current/title-29/section-2560.503-1) (180 days, and your free right to the claim file) and [45 CFR 147.136](https://www.ecfr.gov/current/title-45/section-147.136) (4 months, and what qualifies), explained at [HealthCare.gov](https://www.healthcare.gov/appeal-insurance-company-decision/external-review/) . Expedited review is decided in about 72 hours under both sections.

Reading either regulation from a script rather than a browser: eCFR answers automated fetches with a challenge page, so the same two sections are mirrored as government PDFs at [govinfo.gov (29 CFR 2560.503-1)](https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol9/pdf/CFR-2024-title29-vol9-sec2560-503-1.pdf) and [govinfo.gov (45 CFR 147.136)](https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/pdf/CFR-2024-title45-vol2-sec147-136.pdf) .

This page presents federal statistics and a general description of appeal rights created by federal law. It is not legal, medical, or insurance advice, and no outcome is guaranteed. Your denial letter and plan documents govern your specific case. Free help is available from your state's Consumer Assistance Program and from the federal Marketplace at HealthCare.gov.

Problem solved: You have both dates for your Avera Health Plans, Inc. notice, you know that South Dakota runs the external review itself, and you have the letter, free, on this screen, tonight.

## The pages that answer the next question

- [Every insurer reporting in South Dakota](/states/south-dakota) , the state's own row, the 3 companies filing there, and the South Dakota insurance department's consumer number, read at source.

- [AvMed, Inc. in Florida](/insurers/avmed-inc--fl) , 24.7% of in-network claims denied, 181,070 of them, the neighboring record in this file.

- [Blue Care Network of Michigan in Michigan](/insurers/blue-care-network-of-michigan--mi) , 30.9% of in-network claims denied, 1,248,675 of them, the neighboring record in this file.

- [Blue Cross and Blue Shield of Alabama in Alabama](/insurers/blue-cross-and-blue-shield-of-alabama--al) , 16.1% of in-network claims denied, 3,008,219 of them, the neighboring record in this file.

- [If your employer pays the claims itself](/self-funded-denial) , then Avera Health Plans, Inc. is only administering the plan, your state's external review has no power over the denial, and the route is federal. It is the first question our own calculator asks. 3 insurers report in South Dakota; whether your plan is one of theirs at all is what that page settles.

- [If it was refused before the treatment](/prior-authorization-denied) , a prior-authorization refusal from Avera Health Plans, Inc. runs on the same two federal clocks as a denied claim, and it can be appealed while the treatment is still ahead of you. 95,138 in-network claims were denied in South Dakota in this release; a refusal before the treatment is not counted among them and is appealed the same way.

- [Before you pay a lawyer](/before-you-call-a-lawyer) , two free appeals run before anyone bills you by the hour, and Avera Health Plans, Inc. has to hand you the claim file for nothing under 29 CFR 2560.503-1. Free help in South Dakota starts with the state consumer line printed on that state's page.

- [All 152 insurer-state records](/insurers) , the whole table, ranked, with Avera Health Plans, Inc. in it and the 3 that file in South Dakota beside it.

Your dates are ready. [Write the letter, free](/appeal-letter)

## The two federal clocks

The clock your letter has to describe, in actual dates Whatever else is on the page, these two dates are the page. You have 180 days from the date on your denial notice to file the internal appeal, and then 4 months from the final internal denial to ask for an independent external review. If waiting would seriously jeopardize your health you can ask for both to be expedited, decided in about 72 hours . Both timeframes are federal, not your insurer's choice, 29 CFR 2560.503-1 ( PDF ) and 45 CFR 147.136 ( PDF ), in plain English at HealthCare.gov , and your own denial letter states the ones that govern your plan. The PDFs are the same sections on govinfo.gov, which serves them without a challenge page, so an automated reader can check these two dates as easily as you can.

## How rare the second appeal is

You are not alone, measured rather than said: 83,907,852 in-network claims were denied in a single plan year, and only 4,918 of them, one in 17,061, ever reached the independent review stage. Of the ones that did, 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) were overturned.

## What is free here, and what the one paid thing costs

Denied a claim? Insurers upheld 165,863 of the 262,982 internal appeals counted in 2024, 63.1% ( KFF ). The win is at independent external review, and the only way to arrive there is to run the internal stage on time, in the right order, with the record intact. That sequence is what the Appeal Kit is. Get my Appeal Kit, $29 One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com. Get my Appeal Kit, $29 Everything you need for your appeal: your two deadlines, the argument that fits your denial reason, the letters, a brief for your doctor on what the reviewer checks, and the external review request. One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com.

## What we will not pretend

What we will not pretend. We cannot overturn your denial. Only your plan, or an independent reviewer, can do that. We cannot make your plan cover a service it genuinely excludes. We cannot guarantee external review applies to your denial. It covers medical judgment, experimental or investigational determinations, and rescission, a purely administrative denial may not qualify, and we say so on those pages rather than selling you past it. We have no customer testimonials and publish none. Our evidence is the federal dataset and the regulation cites, both of which you can check.

## Every page on this site

Home Start here Insurers By company States Denial reasons Use cases How to appeal Ranked by denial rate The external-review gap Write the letter, free Deadline calculator Self-funded plan? Prior authorization denied Medicare WISeR denial Denial code CO-50 Before you call a lawyer Attorney for a denied claim Your denial letter United Healthcare denying claims Time limits on a claim Appeal a Medicare denial About Editorial policy How we compare Privacy Terms For machines: llms.txt openapi.json changes.json the composed answer this page as markdown

## Which release these figures are

Which release these figures are Every number on this page is the plan-year 2027 Transparency in Coverage file, issued October 22, 2026, covering plan-year 2025 claims. This is the newest plan year CMS has published: there is no Transparency in Coverage file for a plan year after 2027. The dataset list is at data.healthcare.gov . A test in this site’s build fetches that list on every run and fails if CMS publishes a plan year we have not acknowledged here. Every earlier release, plan-year 2024, plan-year 2025, plan-year 2026, is kept alongside it so the record is visible rather than a single year’s snapshot; /about says what changed between them. From the plan-year 2024 release to the plan-year 2026 release, external reviews filed went from 2,336 to 5,881. Overturned reviews went from 32.8% in the plan-year 2026 release to 22.2% in plan-year 2027, or from 32.6% to 32.6% without SelectHealth. We do not compare filed or overturned counts across plan-years 2026 and 2027. Some issuers may have counted pre-service appeals in their 2026 cells.

## Where these numbers come from

Where these numbers come from Counts: CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain . Rights and timeframes: 29 CFR 2560.503-1 (180 days, and your free right to the claim file) and 45 CFR 147.136 (4 months, and what qualifies), explained at HealthCare.gov . Expedited review is decided in about 72 hours under both sections. Reading either regulation from a script rather than a browser: eCFR answers automated fetches with a challenge page, so the same two sections are mirrored as government PDFs at govinfo.gov (29 CFR 2560.503-1) and govinfo.gov (45 CFR 147.136) .

## Who publishes this

Denial Facts publishes federal data about health insurance claim denials. We are independent: not affiliated with, endorsed by, or acting for any insurer, government agency, or review organization. We are not a law firm, a medical provider, or an insurance producer, and nothing here is legal, medical, or insurance advice. Data: CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain. Figures cover individual-market Qualified Health Plans on the federal Exchange and come from the plan-year 2027 release, issued October 22, 2026, covering plan-year 2025 claims. This is the newest plan year CMS has published: there is no Transparency in Coverage file for a plan year after 2027. See where the data comes from .

## Sources

- CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain: https://data.healthcare.gov/
- 29 CFR 2560.503-1 (180 days, and your free right to the claim file): https://www.ecfr.gov/current/title-29/section-2560.503-1
- 45 CFR 147.136 (4 months, and what qualifies): https://www.ecfr.gov/current/title-45/section-147.136
- HealthCare.gov on external review: https://www.healthcare.gov/appeal-insurance-company-decision/external-review/

Cite: Axion Labs — Denial Facts, "Avera SD appeal form and deadline", https://denialfacts.com/insurers/avera-health-plans-inc--sd (checked 2026-11-04). free to quote with the URL.