Medica Community Health Plan claim denials in Wisconsin: the federal figures
Medica Community Health Plan denied 12.3% of in-network claims in Wisconsin — 54,813 claims out of 445,056. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Medica Community Health Plan) | 153 | 67.3% |
| External review (independent) | 0 | — |
What Medica Community Health Plan denies most
The most common denial reason recorded for Medica Community Health Plan plans in Wisconsin is other reasons. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Other reasons | 22,493 | 45.5% |
| Administrative reason | 12,421 | 25.1% |
| Member not covered | 7,055 | 14.3% |
| Service excluded from the plan | 3,540 | 7.2% |
| Provider out of network | 2,440 | 4.9% |
| Referral required | 1,444 | 2.9% |
What to do if Medica Community Health Plan 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. Medica Community Health Plan overturned 67.3% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Medica Community Health Plan. 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 Medica Community Health Plan 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 Medica Community Health Plan's denial rate high?
12.3% 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 Medica Community Health Plan ignore the external decision?
No. External review decisions are binding on the plan.