Network Health Plan claim denials in Wisconsin: the federal figures
Network Health Plan denied 14.5% of in-network claims in Wisconsin — 35,043 claims out of 242,187. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Network Health Plan) | 18 | — |
| External review (independent) | — | — |
What Network Health Plan denies most
The most common denial reason recorded for Network Health Plan plans in Wisconsin is administrative reason. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Administrative reason | 11,463 | 31.2% |
| Other reasons | 9,070 | 24.7% |
| Referral required | 4,688 | 12.8% |
| Member not covered | 4,358 | 11.9% |
| Service excluded from the plan | 2,809 | 7.7% |
| Benefit limit reached | 2,104 | 5.7% |
| Provider out of network | 1,407 | 3.8% |
| Not medically necessary | 757 | 2.1% |
| Experimental or investigational | 30 | 0.1% |
What to do if Network 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.
- If they say no again, go external. An independent organization reviews it — not Network 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 Network 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 Network Health Plan's denial rate high?
14.5% 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 Network Health Plan ignore the external decision?
No. External review decisions are binding on the plan.