PA says new process to appeal insurance denials has helped flip 100 claims already

24 June 2024- The Pennsylvania Insurance Department (PID) today announced that, through the Department’s independent external review process for Pennsylvanians who submit an eligible request, over 100 Pennsylvanians successfully appealed denied claims. The independent external review process continues the current administration’s efforts, they say, to provide resources that protect Pennsylvanians and make state government more accessible for all Pennsylvanians via the new state website where the third-party review process can be accessed at no cost. 

“In the past, too few people challenged insurer denials through internal or independent external review processes, and we are pleased to see more Pennsylvanians use their right to appeal denials to ensure they are provided benefits to which they are entitled; benefits they paid for,” said Pennsylvania Insurance Commissioner Michael Humphreys. “But the data is clear. With over half of denied claims being overturned by an independent reviewer, health insurers can do a better job of reviewing requests for services. A consumer shouldn’t have to appeal a denial to access clearly covered benefits. Because the Commonwealth now oversees the independent external review process, PID is addressing these cases in a timely manner, ensuring Pennsylvanians are treated fairly.”   

The bipartisan Act 146 of 2022 brought the independent external review process to the state level, providing PID the ability to oversee the process for determination of eligibility for the review, communication with members, and assignment of the certified independent review organization.     

After Pennsylvanians complete the internal appeal process with their insurer when an item or service is denied, they may submit a request through PID’s website for an independent external review to be completed by a certified independent review organization detailing why a service, treatment, or benefit should be covered by their health plan. PID, in coordination with the Commonwealth Office of Digital Experience (CODE PA), launched this website in January 2024, a user- friendly, customer-oriented process that walks Pennsylvanians through the right steps. The review process website is CODE PA’s second public product launch and tool designed to help Pennsylvanians engage with their state government online.     

The independent external review only applies to commercial insurance purchased directly from an insurance company, through Pennie or by employers for their employees (not self-funded health benefit plans). Consumers who receive their health insurance through their employer should ask their employer to confirm if they have coverage through a self-funded benefit plan. 

Once the request for external review is received by PID, consumers will know within five business days if their denial is eligible for review. If eligible for an independent external review, consumers will receive more information within 15 business days from receipt of the notice to inform them of the independent review organization assigned to their case. Additionally, consumers may be asked to submit additional medical records or documentation to the third-party reviewer, who has 45 calendar days from assignment to make a final decision. Most requests receive a final decision in less than 60 days from the date the independent review request is received by PID. For urgent situations, a more expedited process is available. 

If eligible, the certified independent review organization, with experienced doctors and health care professionals, will review the consumer’s case and medical records. If the independent review organization determines that the disputed denial should be covered, the consumer’s insurer will be required to do so. Independent review decisions are final and binding. 

Consumers with questions about this process may visit the PID’s website or contact PID’s Consumer Services Bureau at pa.gov/reviewmyclaim or by calling 1-877-881-6388.