State offers Pennsylvanians help in overturning denied healthcare claims

The Pennsylvania Insurance Department (PID) announced Wednesday that hundreds of Pennsylvanians successfully appealed denied health service claims through a new Independent External Review process.

The external review process overturned more than 50% of appealed denials, according to a release.

“PID is glad to see more Pennsylvanians taking advantage of their rights to appeal health insurance claim denials to get their claims rightfully paid, where appropriate,” Pennsylvania Insurance Commissioner Michael Humphreys said in statement. “Governor Shapiro tasked our department with making state government more accessible and bolstering consumer protections to deliver real results for Pennsylvanians. PID takes its central role in the appeals process seriously.

“As families across the commonwealth continue to challenge claims denials, PID will keep working hard to deliver wins for consumers and ensure Pennsylvanians can benefit from this process for years to come,” added Humphreys.

Per the release, the independent external review provides Pennsylvanians an additional opportunity to appeal a denial after their health insurance company completes an internal review process. Prior to the bipartisan enactment of Act 146 of 2022, Pennsylvanians could only request an external review through a federal government process. Act 146 brought the external review to the state level, providing a faster outlet for Pennsylvanians to request a review.

PID now oversees this process and determines if a claim is eligible for review, any related communications with consumers, and the assignment of the reviews to a certified independent review organization.

In January 2024, PID, in coordination with the Commonwealth Office of Digital Experience, launched a website that walks Pennsylvanians through the steps of the review process.

The external review process is available only for commercial insurance policies purchased directly from an insurance company, through Pennie or by employers for their employees. Pennsylvanians who receive their health insurance through their employer should ask their employer to confirm whether they have coverage through a self-funded benefit plan or an insured plan.

The Independent Review Process works as follows:

• A Pennsylvania insurance consumer must first complete the appeal process for a denied health item or service with their insurer.
• After the consumer completes the internal appeal process with their insurer, they may submit a request detailing why a service, treatment, or benefit should be covered by their health plan to PID for an independent external review by a certified independent review organization.
• PID receives the request for an external review and works with the insurer to determine if the request is eligible for independent external review.
• Within five business days, the insurer notifies the consumer if their denial is eligible for review.
• If the request is eligible for external review, PID notifies the consumer that an independent review organization was assigned to their case and that the consumer has 15 business days from receipt of the notice to submit any supporting information.
• The independent review organization, with experienced doctors and health care professionals, reviews the consumer’s case and medical records, and will make a final decision within 45 days from assignment.
• If the independent review organization determines that the disputed denial should be covered, the consumer’s insurer will be required to do so.

Independent external review decisions are final and binding. Most consumers receive a final decision less than 60 days from the date the independent review request is received by PID. For situations where the member’s life or health would be placed in danger by the standard timeframe, an expedited process is available.

Pennsylvanians with questions about the Independent External Review process or about their insurance, health plan or a denied claim should contact the PID’s Consumer Services Bureau.