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Insurer Denial Rates

insurer_denial_rates
Read-onlyIdempotent

Which health insurers deny the most claims — US marketplace issuers ranked by the share of in-network claims they denied, for plan year 2026. Answers "what percentage of claims does my insurance company deny", "which insurer denies the most", "how often does deny claims", and comparisons between insurers in a state. Returns each issuer with claims received, claims denied, the denial rate as a percentage, and how many marketplace plans it offers. Filter by state (two-letter code) or by market — medical plans (Individual QHP), standalone dental (Individual SADP, which denies at much higher rates than medical), or small-group SHOP; the market filter selects which ISSUERS to include, since CMS publishes these counts per issuer rather than per market. Sourced from the CMS Transparency in Coverage Public Use File, which insurers report into under federal rule; covers HealthCare.gov states only, so issuers on state-run exchanges such as California and New York are not present.

Input Schema

TableJSON Schema
NameRequiredDescriptionDefault
limitNoHow many issuers to return (default 20, max 200).
orderNo"highest" (default) ranks the biggest deniers first; "lowest" ranks the smallest.
stateNoTwo-letter US state code to filter by, e.g. "TX", "FL". Omit for all states.
marketNoRestrict to issuers participating in a market: "medical" / "QHP", "dental" / "SADP" for standalone dental, or "SHOP" for small-group. Selects issuers; it does not split an issuer's claim counts, which CMS reports per issuer. Omit for all three.

Schema Changelog

Changes observed during successful MCP inspections.

  1. First observed

TDQS

A4.5/5.0
Behavior4/5

Does the description disclose side effects, auth requirements, rate limits, or destructive behavior?

Annotations already declare readOnlyHint, openWorldHint, idempotentHint, and destructiveHint=false. The description adds valuable context beyond this: it clarifies the data is from CMS PUF, covers only HealthCare.gov states, and explains that the market filter selects issuers rather than splitting counts. It also explains the 'dental denies at much higher rates' nuance, which helps agents interpret results. It doesn't mention pagination or response format, but with openWorldHint true, missing data is expected.

Agents need to know what a tool does to the world before calling it. Descriptions should go beyond structured annotations to explain consequences.

Conciseness4/5

Is the description appropriately sized, front-loaded, and free of redundancy?

The description is dense but well-organized. It starts with the core purpose, then addresses common user questions, describes the return fields, explains the filters with caveats, and ends with data source and limitations. While it's a bit long, it avoids redundancy and front-loads the key information (what it does, what it returns). The structure is logical and information-dense, with each sentence adding value.

Shorter descriptions cost fewer tokens and are easier for agents to parse. Every sentence should earn its place.

Completeness4/5

Given the tool's complexity, does the description cover enough for an agent to succeed on first attempt?

Given the tool's moderate complexity (4 optional params, no output schema), the description is quite comprehensive. It covers purpose, data source, filter semantics, data coverage limitations, and return fields (claims received, denied, denial rate, plans offered). It doesn't discuss error conditions or edge cases (e.g., no matching issuers), but with no required params and no output schema, the main contextual needs are addressed. A small gap is not mentioning sorting behavior aside from order param, but that's in schema.

Complex tools with many parameters or behaviors need more documentation. Simple tools need less. This dimension scales expectations accordingly.

Parameters4/5

Does the description clarify parameter syntax, constraints, interactions, or defaults beyond what the schema provides?

Schema coverage is 100%, so parameters like state, market, limit, and order are already documented. The description adds critical context: it explains the market parameter's semantics in depth (it selects issuers, not claims counts, and gives examples like 'Individual QHP' and 'Individual SADP'), which goes beyond the schema's basic definition. It also explains that 'state' is two-letter code, though that's in the schema. This added value justifies above baseline 3.

Input schemas describe structure but not intent. Descriptions should explain non-obvious parameter relationships and valid value ranges.

Purpose5/5

Does the description clearly state what the tool does and how it differs from similar tools?

The description clearly states the tool's purpose: ranking health insurers by claim denial rates. It specifies the data source (CMS TiC PUF), the plan year (2026), and the exact questions it answers. It also distinguishes itself from sibling tools like insurer_appeal_outcomes, insurer_denial_coverage, and insurer_denial_profile by its focus on denial rates and issuer-level ranking, making selection unambiguous.

Agents choose between tools based on descriptions. A clear purpose with a specific verb and resource helps agents select the right tool.

Usage Guidelines5/5

Does the description explain when to use this tool, when not to, or what alternatives exist?

The description provides explicit guidance on when to use this tool: for questions about denial percentages, comparisons between insurers, and state-level breakdowns. It also notes important exclusions (state-run exchanges like CA and NY are not covered) and explains the market filter's behavior (selects issuers, not claims splits), which helps agents decide if this is the right tool or if a sibling like insurer_denial_profile might be more appropriate.

Agents often have multiple tools that could apply. Explicit usage guidance like "use X instead of Y when Z" prevents misuse.

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