New Pennsylvania program will review health insurance denials when people lose out on coverage for care

The Independent External Review program will take cases from people who believe their insurer has incorrectly denied them health care coverage.

A close-up of a health insurance coverage form being held by someone.

FILE: In this Monday, Dec. 4, 2017, file photo, a woman looks over her health insurance benefit comparison chart which shows out-of-network coverages dropped for 2018, at her home office in Peachtree City, Ga. Insurers that administered health plans in Pennsylvania’s Affordable Care Act marketplace denied more than 2 million claims in 2022, but only 2,165 internal appeals were filed by policyholders. (AP Photo/David Goldman, File)

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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.

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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.

The state has already been providing review services for the Children’s Insurance Program and Medicaid. But with the new program, Logue said an estimated 1.5 million more people with private insurance will now be able to request help with denials.

Only a small percentage of people complete appeals for insurance decisions, according to a Pennsylvania Insurance Department report.

Insurers that administered health plans in Pennsylvania’s Affordable Care Act marketplace denied more than 2 million claims in 2022, but only 2,165 internal appeals were filed by policyholders.

Of those appeals, about 53% of denials were overturned, according to state data.

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Logue said she hopes the new review program will encourage more people to pursue appeals and reviews when they believe they’ve been wrongly denied coverage for necessary health care.

“It’s a really important thing that people are doing and using those rights that they have to challenge those denials,” Logue said. “And that alone, our oversight in seeing that, it should really serve as a notice to health insurers to do a better job reviewing the claim the first time.”

Denials from self-funded health plans, which is a specific kind of employer-sponsored insurance, are not eligible for the review program.

The state program does not serve people 65 and older and some younger people with disabilities who get their insurance through Medicare, which has its own appeals process through federal agencies.

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