Pennsylvania launches external review program for health claim denials
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When people get denied insurance coverage for a medical procedure or medication, they can usually appeal that decision directly with their health insurer. But if that doesn’t work, people are often left with limited options.
Now, a new Pennsylvania program will take up these cases and offer another chance for people to appeal the insurance company’s decision.
The Pennsylvania Insurance Department’s Independent Review Program launched this month. It assigns eligible cases to teams of doctors, specialists and other experts who determine if an insurance denial was correctly or incorrectly issued.
If the independent review teams, contracted by the state, determine that a patient was wrongly denied coverage, then health insurers must overturn the denial and cover the service, medication or therapy equipment.
“If people believe it’s a service that they should have covered, we want to tell them to keep pushing,” said Shannen Logue, state Insurance Department deputy commissioner. “We want to empower the people to know that we’re here. We’ve made a really easy solution online for people so they can go ahead and request that [review].”
The program will take cases submitted by residents who have health plans they purchased through Pennie, the state’s Affordable Care Act marketplace; people who buy their insurance directly from a company; and workers who get health plans through their employers.
Eligibility is determined within five days after someone submits a request.
The program will then assign the case to a contracted independent review organization and team, which is followed by a 15-day “pause period” in which both the patient and the review team gathers additional documents and information relevant to the denial.
Logue said review teams have 45 days to analyze the case. Most people will receive a decision within 60 days.
The program has an expedited process for people facing urgent life-threatening or serious health risks who may need a decision sooner.
The new review program is the result of state legislation signed into law by former Gov. Tom Wolf in 2022. It sought to expand state-based review services and support for people and their health insurance needs.
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