How do insurance denial appeals work?

Upload your denial letter and Lysco analyzes it, identifies the denial reason, cites applicable laws (ACA, ERISA, state regulations), and generates a customized appeal letter. You review and submit it yourself.

What is the success rate for insurance appeals?

It varies by plan type. For ACA marketplace plans, about 44% of appealed denials are overturned (KFF, 2023). For Medicare Advantage, it can be as high as 83% (HHS OIG). Many denials stem from billing or administrative errors that get fixed when challenged. Individual results vary.

Is Lysco a law firm or medical practice?

No. Lysco is an informational tool that helps you understand your rights and options. It is not a law firm, medical practice, or insurance company. For specific legal or medical situations, consult a licensed professional.

How much does Lysco cost?

Analysis is always free and your first appeal letter is free too. Upgrade to Pro ($29/mo) or Annual ($199/year) for unlimited appeal letters, insurer playbooks, and benefits finder. Cancel anytime.

Is my health data secure on Lysco?

Yes. Lysco uses AES-256 encryption at rest, TLS for data in transit, and row-level security so only you can access your data. We never sell your data and follow HIPAA-aligned security practices.

Centene / WellCare / Ambetter

Also known as: Centene, WellCare, Ambetter, WellCare Health Plans, Centene Corporation, Health Net

MedicaidMedicare AdvantageACA MarketplaceIndividual

Common Denial Patterns

Prior authorization denials for specialty care
Medical necessity denials for inpatient stays
Narrow network denials (limited provider availability)
Step therapy enforcement for specialty medications

Appeal Best Practices

1For Medicaid denials, invoke state fair hearing rights — these are stronger than commercial plan appeals
2Document network adequacy issues (provider shortages are common in Centene plans)
3Reference state Medicaid regulations, not just federal rules
4File with the state Medicaid agency if the plan is unresponsive

Known Weaknesses

Narrow networks may create access issues — document provider unavailability
State Medicaid fair hearings are independent of the plan (better odds than internal appeals)
CMS and state regulators have scrutinized Centene's Medicaid denial practices
Ambetter marketplace plans have been subject to network adequacy complaints

Contact & Response

Best Contact Method

Member services > Written appeal > State fair hearing (Medicaid)

Typical Response Time

30 days (internal), varies by state for fair hearings

Internal Criteria Used

MCG
InterQual
Centene internal guidelines

State-Specific Notes

Staywell (Centene) is major Medicaid MCO — use FL fair hearing process

Superior HealthPlan (Centene) — TX HHS fair hearing available

Peach State Health Plan (Centene) — GA Department of Community Health oversees

General Tips

Centene is the largest Medicaid managed care organization in the US
Ambetter is Centene's ACA marketplace brand — same company, different branding
WellCare is Centene's Medicare Advantage brand
Use state Medicaid fair hearing rights for Medicaid plan denials

Have a denial from Centene / WellCare / Ambetter?

Upload your denial letter for free analysis. Lysco uses Centene / WellCare / Ambetter-specific intelligence to identify weak points and draft your appeal.

Upload Your Denial — Free

This information is for educational purposes based on publicly available data including CMS reports, state insurance department filings, and published insurer guidelines. It does not constitute legal, medical, or financial advice. Individual results vary. Verify all information independently and consult qualified professionals before acting.