Pennsylvania Launches Independent Review Program for Insurance Denials: What You Need to Know

PHILADELPHIA, PA – Denied insurance coverage for a medical procedure or medication can often leave people feeling helpless. However, a new program in Pennsylvania aims to provide a lifeline for those in this situation.

The Independent Review Program, launched by the Pennsylvania Insurance Department, offers a second chance for individuals to appeal their insurance company’s decision. This program assigns eligible cases to teams of doctors, specialists, and experts to determine the correctness of the insurance denial.

If the review teams conclude that a patient was wrongly denied coverage, the health insurer must overturn the denial and cover the service, medication, or therapy equipment. Shannen Logue, the state Insurance Department deputy commissioner, encourages people to keep pushing for coverage if they believe it is warranted.

The program is open to residents with health plans purchased through Pennie, the state’s Affordable Care Act marketplace, as well as individuals who purchase insurance directly from a company and workers with employer-provided health plans. Eligibility is determined within five days of submitting a request to the program.

Once a case is assigned to a review organization and team, there is a 15-day “pause period” for gathering additional documents and information relevant to the denial. The review teams then have 45 days to analyze the case, with most decisions being issued within 60 days.

The new review program, signed into law by former Gov. Tom Wolf, seeks to provide expanded state-based review services and support for people and their health insurance needs. This program is a welcome development for those who have experienced the frustration of insurance denials, offering a path to appeal and potentially receive the coverage they deserve.