2026 Healthcare Claim Denial Statistics & Benchmarks
Every statistic on this page is published, attributed, and free to cite in academic research, trade journalism, or board presentations with attribution to RecoupOps.
National Claim Denial Metrics
Across all medical claims submitted nationwide
Due to manual labor constraints and prohibitive rework costs
When providers invest the hours to submit comprehensive appeals
HFMA/MGMA estimates range between $25 and $118 per claim
A direct friction tax on clinical practices and billing teams
Based on newly published CY2025 federal compliance filings
Rising consistently every year since 2022
Driven by margin compression and billing labor shortages
HFMA First-Pass Denial Target Bands
How does your organization compare against published Healthcare Financial Management Association operational targets?
The CMS-0057-F Prior Authorization Dataset
Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), major insurers were required to publish calendar-year 2025 prior-authorization approval, denial, and appeal overturn rates by March 31, 2026. Sourced from KFF's August 2026 comprehensive analysis.
Major Payer Prior-Authorization Denial & Overturn Rates
| Payer Organization | PA Denial Rate | Expedited Denial Rate | Overturned on Appeal | Median Response | Operational Intelligence | Guide |
|---|---|---|---|---|---|---|
| Centene | 15% | 13% | 93% | 1.0 days | Overwhelming majority of denials overturned upon timely submission of chart notes. | Playbook |
| CVS Health (Aetna) | 8% | 11% | 89% | 1.1 days | High overturn rate when CPB (Clinical Policy Bulletins) are explicitly referenced. | Playbook |
| Elevance Health | 5% | 3% | 75% | 1.4 days | Lowest baseline PA denial rate, but responsive to peer-to-peer documentation attachments. | Playbook |
| Humana | 7% | 10% | 64% | 0.9 days | Strict Medicare Advantage guideline enforcement; fast response to online portal filings. | Playbook |
| UnitedHealth Group | 17% | 11% | 60% | 1.2 days | Highest PA denial rate among top 6 commercial carriers; high overturn on level 1 clinical re-review. | Playbook |
| Kaiser Permanente | 13% | 7% | 40% | 0.8 days | Closed HMO network rules require precise out-of-network continuity citation. | Playbook |
Prior-Authorization Denial & Overturn Rates by Insurance Market (CY2025)
| Market Segment | Standard PA Denial Rate | Expedited PA Denial Rate | Overturned on Appeal |
|---|---|---|---|
| Medicare Advantage | 12% | 10% | 67% |
| Medicaid Managed Care (MCO) | 14% | 12% | 47% |
| ACA Individual Marketplace (FFM) | 18% | 16% | 43% |
Source: KFF analysis of insurer CMS-0057-F compliance disclosures, August 2026.
Technology & AI Adoption in Revenue Cycle (2025–2026)
From Experian Health's State of Claims 2025 research survey of 250 revenue cycle executives:
Only 14% have implemented AI tooling today, creating a massive competitive opportunity.
Reducing claim denials ranks as the #1 operational priority for health system executives.
Willing to replace existing claims systems entirely for a demonstrably compelling ROI.
Academic & Editorial Citation Guide
All datasets published on this page are licensed under Creative Commons (CC BY 4.0). You are free to cite these figures in articles, whitepapers, or reports with attribution.
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