MercyCare HMO, Inc. claim denials in Wisconsin: the federal figures
MercyCare HMO, Inc. denied 10.1% of in-network claims in Wisconsin — 22,765 claims out of 224,919. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to MercyCare HMO, Inc.) | 26 | 61.5% |
| External review (independent) | — | — |
What MercyCare HMO, Inc. denies most
The most common denial reason recorded for MercyCare HMO, Inc. plans in Wisconsin is other reasons. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Other reasons | 11,646 | 74.8% |
| Service excluded from the plan | 2,084 | 13.4% |
| Administrative reason | 705 | 4.5% |
| Referral required | 526 | 3.4% |
| Member not covered | 458 | 2.9% |
| Provider out of network | 156 | 1% |
What to do if MercyCare HMO, 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. MercyCare HMO, Inc. overturned 61.5% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not MercyCare HMO, 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 MercyCare HMO, 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 MercyCare HMO, Inc.'s denial rate high?
10.1% 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 MercyCare HMO, Inc. ignore the external decision?
No. External review decisions are binding on the plan.