Shapiro Administration’s Independent External Review Helps Hundreds of Consumers Receive Health Care Benefits Their Insurers Originally Denied | Insurance Department |[...]

Harrisburg, PA - The Pennsylvania Insurance Department (PID) today announced that, since 2024, the Commonwealth-run Independent External Review process has overturned about 48% of eligible claims submitted, meaning hundreds of Pennsylvanians received health care benefits their insurers originally refused to cover. This success over the first two years builds on the Shapiro Administration's continued commitment to ensuring Pennsylvanians know about available resources to keep money in Pennsylvanians' pockets.

"The data speaks for itself - Pennsylvanians are benefiting from the external review process," said Pennsylvania Insurance Commissioner Michael Humphreys. "We're encouraged to see that many Pennsylvanians are taking advantage of this valuable resource, winning their appeals, and are now able to access benefits that were initially denied."

The independent external review process helps Pennsylvanians by providing them with an additional outlet to exercise their right to appeal a denied health insurance claim. Pennsylvanians are eligible for an external review when the claim continues to be denied after an internal appeal to the insurance company. At that point, Pennsylvanians can request PID to assign the appeal to an independent reviewer. PID continues to encourage anyone who has been denied coverage to file an appeal and use the Independent External Review process.

In January 2024, the Shapiro Administration launched a user-friendly, customer-oriented website that walks Pennsylvanians through the steps of the review process. PID referred 1,353 eligible cases for an external review through an Independent Review Organization (IRO) since the process started in 2024. Of those requests, 655 initially denied insurance claims were overturned by independent reviewers.

The external review process is available only for commercial insurance policies purchased directly from an insurance company, through Pennie, or for policies purchased by employers for their employees (not self-funded health benefit plans). 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.

How the Independent Review Process Works:

• First, a consumer must appeal a denied insurance claim with their insurance company and follow the internal appeal process to completion;
• If the claim is still denied after completing the insurance company's internal appeal process, the consumer submits a request with PID for an Independent External Review, detailing why a service, treatment, or benefit should be covered by the health plan;
• 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; and
• 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 within 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 their insurance or who wish to file a complaint can visit pa.gov/consumer or call 1-866-PA-COMPLAINT (1-866-722-6675).