Medica Insurance Company claim denials in Missouri: the federal figures
Medica Insurance Company denied 17.1% of in-network claims in Missouri — 114,296 claims out of 669,658. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Medica Insurance Company) | 330 | 53% |
| External review (independent) | 0 | — |
What Medica Insurance Company denies most
The most common denial reason recorded for Medica Insurance Company plans in Missouri is other reasons. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Other reasons | 35,680 | 49% |
| Administrative reason | 15,547 | 21.3% |
| Benefit limit reached | 7,205 | 9.9% |
| Member not covered | 7,205 | 9.9% |
| Service excluded from the plan | 4,945 | 6.8% |
| Referral required | 1,465 | 2% |
| Provider out of network | 801 | 1.1% |
What to do if Medica Insurance Company 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 Insurance Company overturned 53% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Medica Insurance Company. 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 Insurance Company 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 Insurance Company's denial rate high?
17.1% against a national average of 16% across the plans in this dataset. It is above 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 Insurance Company ignore the external decision?
No. External review decisions are binding on the plan.