HARRISBURG, PA — Hundreds of Pennsylvanians have gained access to previously denied health care coverage through a state-run appeal process that overturns nearly half of eligible insurance denials.
What This Means for You
- You can appeal denied health insurance claims beyond your insurer
- Nearly half of eligible appeals are overturned
- The process is free and decisions are binding on insurers
Since 2024, Pennsylvania’s Independent External Review process has overturned about 48 percent of eligible denied claims, according to the Pennsylvania Insurance Department. That has resulted in 655 reversals out of 1,353 cases reviewed by independent medical experts.
The process gives consumers an additional step after their insurance company denies a claim and upholds that denial through its internal appeal system.
How the Review Process Works
An independent external review is a state-managed appeal in which a third-party medical expert evaluates whether a denied treatment, service, or medication should be covered.
Consumers must first complete their insurer’s internal appeal process. If the denial remains, they can request a review through the state.
The process includes:
- Submission of a request to the Pennsylvania Insurance Department explaining why coverage should be approved
- Eligibility review coordinated between the state and the insurer
- Assignment of the case to an independent review organization
- A final determination by medical professionals within 45 days
If the independent reviewer determines the claim should be covered, the insurer is required to pay for the service. Decisions are final and binding.
Most cases are resolved within 60 days, though expedited reviews are available when delays could jeopardize a patient’s health.
Who Is Eligible
The program applies to commercial health insurance plans purchased directly, through Pennie — the state’s health insurance marketplace — or through employer-sponsored insured plans.
It does not apply to self-funded employer plans, which are regulated differently. Consumers are advised to confirm their plan type with their employer.
State Encourages More Appeals
State officials said the high reversal rate shows the value of pursuing appeals.
“The data speaks for itself – Pennsylvanians are benefiting from the external review process,” Insurance Commissioner Michael Humphreys said.
Officials also launched a step-by-step online guide in 2024 to help residents navigate the process:
https://www.pa.gov/services/insurance/request-a-review-if-your-health-insurance-denied-a-treatment-medication-or-service
How to Get Help
Pennsylvanians with questions or complaints about insurance coverage can visit:
https://www.pa.gov/consumer
Residents can also call 1-866-PA-COMPLAINT (1-866-722-6675) for assistance.
Officials said consumers who believe a denial is incorrect should consider filing an appeal to ensure they receive the coverage they are entitled to under their plan.
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