Harrisburg, Pennsylvania — The Pennsylvania Insurance Department (PID) said that 259 Pennsylvanians were able to get their denied health service claims overturned using the PID’s new Independent External Review method.
The external review process overturned 50% of the rejections that were appealed. This helped more Pennsylvanians get the health care they need and was a good start for the first year of the process.
Pennsylvanians have another chance to appeal a decision after their health insurance company finishes an internal review process. This is called an independent external review. Before Act 146 of 2022 was passed by both parties, Pennsylvanians could only ask for an outside review through a process run by the federal government. This law brought the external review to the state level, making it easier for people in Pennsylvania to ask for a review more quickly. PID is now in charge of this process and deciding if a claim can be reviewed. They are also in charge of any contacts with customers and assigning the reviews to a certified independent review organization.
In January 2024, PID and the Commonwealth Office of Digital Experience (CODE PA) released a website that walks Pennsylvanians through the steps of the review process and is easy for people to use.
The external review process is only available for business insurance policies bought from an insurance company, through Pennie, or by companies for their workers. It is not available for self-funded health benefit plans. People in Pennsylvania whose health insurance comes from their jobs should check with their boss to see if they are covered by an insured plan or a self-funded benefit plan.
According to Michael Humphreys, the commissioner of insurance for Pennsylvania, PID is glad to see more people using their rights to appeal health insurance claim rejections to get their claims paid when they should be. Our Department was told by Governor Shapiro to make the state government easier to reach and strengthen consumer protections so that Pennsylvanians could see real results. PID is very serious about its main part in the complaints process. Families all over the Commonwealth will keep fighting claim denials, and PID will keep working hard to win for consumers and make sure that Pennsylvanians can benefit from this process for years to come.
How the review process for independent bodies works:
A Pennsylvania insurance customer must first go through the appeals process with their insurer if they are turned down for a health item or service; After the customer has finished the internal appeals process with their insurance company, they can send a request to PID explaining why a service, treatment, or benefit should be paid by their health plan. This will be looked at by a certified independent review organization.
When PID gets a request for an external review, they work with the insurance to see if the request can be approved for an independent external review. The insurance company tells the customer within five business days if they can appeal their denial; If the request can be reviewed by an outside group, PID will let the consumer know that their case has been given to an independent review organization and that they have 15 business days from the date they receive the notice to send any supporting documents. The independent review organization, which is made up of experienced doctors and health care workers, looks over the patient’s case and medical data and decides within 45 days of being assigned; and If the expert review group decides that the denied claim should be paid for, the consumer’s insurance company will have to follow through.
Decisions made by an independent external review are final and must be followed. Most people get a final decision in less than 60 days from the time PID gets their request for an expert review. There is a faster method for when the member’s life or health would be in danger if the normal time frame was used.
People in Pennsylvania can call or go online to the PID’s Consumer Services Bureau if they have questions about the Independent External Review process, their insurance, their health plan, or a claim that was rejected.
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