Community Health Choice, Inc. claim denials in Texas: the federal figures
Community Health Choice, Inc. denied 15% of in-network claims in Texas — 586,369 claims out of 3,902,036. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Community Health Choice, Inc.) | 661 | 27.7% |
| External review (independent) | 16 | 75% |
What Community Health Choice, Inc. denies most
The most common denial reason recorded for Community Health Choice, Inc. plans in Texas is service excluded from the plan. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Service excluded from the plan | 211,336 | 41.6% |
| Other reasons | 193,075 | 38% |
| Provider out of network | 91,134 | 17.9% |
| Referral required | 6,928 | 1.4% |
| Member not covered | 2,423 | 0.5% |
| Not medically necessary | 1,662 | 0.3% |
| Administrative reason | 980 | 0.2% |
| Benefit limit reached | 611 | 0.1% |
| Experimental or investigational | 88 | 0% |
What to do if Community Health Choice, Inc. denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. Community Health Choice, Inc. overturned 27.7% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Community Health Choice, Inc.. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your Community Health Choice, Inc. appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is Community Health Choice, Inc.'s denial rate high?
15% against a national average of 16% across the plans in this dataset. It is at or below average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal 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.
Can Community Health Choice, Inc. ignore the external decision?
No. External review decisions are binding on the plan.