A New State Process Helps Overturn Denied Health Care Claims

January 08, 2025

The Shapiro administration today announced 259 Pennsylvanians had successfully overturned denied health claims through a new review process from the Pennsylvania Insurance Department (PID).

The new review process stems from the enactment of Act 146 of 2022, a HAP-supported bill that addresses prior authorization challenges and improves access to care.

“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,” said Pennsylvania Insurance Commissioner Michael Humphreys.

Here’s what you need to know:

• About:  The independent external review provides Pennsylvanians an additional opportunity to appeal a denial after their health insurance company completes an internal review process.
  • Most consumers receive a final decision less than 60 days from the date the independent review request is received by PID, state officials said.
• By the numbers:  The new external review process overturned more than 50 percent of appealed denials, state officials said.
• Key detail:  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. 
• New resource:  During January 2024, PID launched a website that outlines how Pennsylvanians can request a review of their claim denial.
• Quotable:  “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,” Humphreys said in a statement.

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 or call (877) 881-6388.