PA Initiates Health Claim Denial Review Program

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TL/DR –

A new program has been launched by the Pennsylvania Insurance Department to help people appeal insurance denials for medical procedures or medications. The Independent Review Program will investigate insurance denial cases and, if it determines a patient was wrongly denied coverage, the insurer must then cover the service, medication or therapy equipment. The program accepts cases from those with health plans purchased through Pennie, the state’s Affordable Care Act marketplace; those who buy insurance directly from a company; and workers with health plans through their employers.


New Pennsylvania Program Takes up Insurance Denial Appeals

The state of Pennsylvania has introduced a novel program designed to take up the mantle on appealing insurance coverage denials for medical procedures or medications. This program provides a second chance for individuals who have exhausting their options with their health insurer.

The Pennsylvania Insurance Department’s Independent Review Program launched recently, offering a fresh pathway for individuals to appeal against denials issued by their health insurance providers. The program involves assigning appeal cases to specialized squads of doctors and experts who assess if the denial was justified.

If the independent review teams, under contract by the state, establish that a patient was incorrectly denied coverage, the health insurers are compelled to revoke the denial and cover the service, medication or therapy equipment. The program’s mission, as articulated by State Insurance Department Deputy Commissioner, Shannen Logue, is to empower people to keep advocating for their rightful coverage.

Submissions for this program are open to residents who purchased health plans through Pennie, Pennsylvania’s Affordable Care Act marketplace, those who buy their insurance directly from a company, and employees receiving health plans from their workplace. After a request is submitted, eligibility is determined within five days.

Once a case is accepted, a contracted independent review organization is tasked with its review. This is followed by a 15-day pause period allowing the patient and review team to garner additional documents and information. Although the entire process generally takes around 60 days, urgent cases with potentially life-threatening or serious health risks can follow an expedited process.

This progressive initiative is the outcome of state legislation signed by former Governor Tom Wolf in 2022, aiming to broaden state-based review services and bolster support for people’s health insurance needs.


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