How to appeal a health insurance denial in Pennsylvania
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Pennsylvania lets you ask an independent reviewer to decide, through Pennsylvania Insurance Department. The deadline to ask: within four months from the date of the Final Adverse Benefit Determination Letter.
Does this apply to you? State external review covers plans regulated by Pennsylvania: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Pennsylvania
Within four months from the date of the Final Adverse Benefit Determination Letter
If your life or health is at serious risk, have your doctor complete the Physician Certification Form and choose 'Expedited Independent External Review' without waiting for the internal appeal to finish; the review organization decides within 72 hours of its assignment.
Free
State-regulated plans (insurance bought in Pennsylvania or through an employer that buys insurance). Self-funded employer plans use the federal process.
Since January 1, 2024 (Act 146 of 2022) PID runs its own process, replacing the federal HHS process; submit to PID online, or print and send by email (RA-IN-ExternalReview@pa.gov), fax (717-231-7960) or mail. Include the final denial letter, insurance card and medical records. Medicaid/CHIP enrollees use their managed care plan's external grievance process instead.
Who to contact
- Pennsylvania Insurance Department
- External review information and forms
- Consumer help line: 877-881-6388
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Pennsylvania?
Within four months from the date of the Final Adverse Benefit Determination Letter
Can I get a fast external review in Pennsylvania?
If your life or health is at serious risk, have your doctor complete the Physician Certification Form and choose 'Expedited Independent External Review' without waiting for the internal appeal to finish; the review organization decides within 72 hours of its assignment.
Does external review cost anything in Pennsylvania?
Free
Do Pennsylvania’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- Request a Review If Your Health Insurance Denied a Treatment, Medication, or Service (PA.gov)
You must request a review within four months from the date of the ‘Final Adverse Benefit Determination Letter.’
- PID news release: state external review process launch (Jan. 8, 2024)
There is no cost for consumers to submit an independent review request.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.