As part of Act 146, Pennsylvanians now have the option to file a complaint with the Pennsylvania Insurance Department if they believe coverage for a medical procedure has been denied.
The state-administered independent third-party review process is available at no cost to Pennsylvanians and can be accessed on a new state website developed by the Commonwealth Office of Digital Experience (CODE PA) team.
Harrisburg, PA – Consistent with Governor Josh Shapiro's commitment to protect consumers and make government more accessible, the Pennsylvania Insurance Department (PID) today launched a state-administered independent appeal process that allows Pennsylvanians to submit for an Independent External Review if they believe their insurer has wrongly denied a claim for covering medical service, treatment, and items.
The state-specific standards went into effect on January 1, 2024, as part of Act 146 that was passed into law in 2022. When coverage for a service is denied, and after consumers complete the internal appeal process with their insurer, they may submit a request to PID using a new website developed by the Commonwealth Office of Digital Experience (CODE PA) for an independent external review to be completed by a certified independent review organization detailing why a service, treatment, or benefit should be covered by their health plan.
“Now that Pennsylvania has taken over the external review process from the federal government, PID has the ability to ensure policyholders are being treated fairly. Our dedicated team will ensure that reviews are completed in a timely manner and consistent with state standards," said Pennsylvania Insurance Commissioner Michael Humphreys. “Pennsylvania consumers who believe they were wrongly denied should know that we have their back – and they should feel empowered to file an independent appeal with us. Too few people challenge denials through internal or external review processes. Our recent Transparency in Coverage Report shows that although only a small number of individuals challenged their claim denials in the past 3 years, a significant number of those appeals had merit and their denials were reversed. Those facts alone should serve as notice to health insurers to do better in reviewing claims the first time around, and the Shapiro Administration will use every tool at its disposal to protect consumers."
The online request for Independent External Review was developed by CODE PA, PID, and Publicis Sapient. The review process website is CODE PA's second public product launch and tool designed to help Pennsylvanians engage with their state government online. The CODE PA team was responsible for the product management, design, copy writing, and user testing, and assisted with the software development.
“Navigating the healthcare system can be overwhelming to many consumers, and so we want to offer a much different experience when they come to the Pennsylvania Insurance Department for help," said Bry Pardoe, Executive Director CODE PA. “We spent time with Pennsylvanians who have been through this process so we could design a system around their needs. It demonstrates how we can simplify people's interactions across state agencies."
If the consumer is eligible, the certified independent review organization, with experienced doctors and health care professionals, reviews the consumer's case and medical records. If the independent review organization determines the disputed request should be covered, the consumer's health plan will be required to do so. Independent review decisions are final and binding. There is no cost for consumers to submit an independent review request.
PID oversees the process for determination of eligibility for the review, communication, and assignment of the certified independent review organization. The external review only applies to commercial insurance purchased by employers for their employees (not self-funded health benefit plans), insurance purchased through Pennie®, or insurance purchased directly from an insurance company. Consumers should ask their employer to confirm whether they have a commercial insurance or a self-funded benefit plan.
Once the request is received by PID, eligibility is determined within five days. If eligible for an independent review, consumers are given 15 business days from receipt of their notice informing them of the independent review organization assigned to their case to submit additional medical records or documentation to the third-party reviewer, who has 45 calendar days from assignment to make a final decision. Most requests should receive a final decision in less than 60 days from the date the independent review request is received by PID. Going forward, PID can view problematic patterns and address systemic issues before additional consumers are harmed.
Consumers with questions about the new process can visit the PID website or contact PID's Consumer Services Bureau at pa.gov/reviewmyclaim or by calling 1-877-881-6388.
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