Overview
If your health plan has denied a service, treatment, or item, you may be eligible to request a review of the decision. You can explain why the Independent External Review should cover your request.
An independent group of experienced doctors and healthcare professionals will review your case.
If the review determines that the request should be covered, your health plan must do so. Independent review decisions are final and binding.
Eligibility
This process applies to insurance that has been:
- Provided by your employer
- Purchased from Pennie®
- Purchased directly from an insurance company
If you have Medicare, you can visit Medicare.gov for more information on filing an appeal.
If you have Medicaid or CHIP, use the External Grievance Review Process. Contact your Managed Care Organization.
Before you request a review, you must go through an internal appeal with your health plan. The internal appeal process can differ by health plan. You will need to reach out to your insurer for information.
Your health plan will then issue a 'Final Adverse Benefit Determination Letter.'
If they deny your request again, you can start an Independent External Review.
You must request a review within four months from the date of the ‘Final Adverse Benefit Determination Letter.’
Required Documents
- A ‘Final Adverse Benefit Determination Letter,’ a denial letter from your health plan.
- Your insurance card.
- Any medical records or materials that show why the request should be covered.
- For Expedited Independent External Reviews: your doctor must also complete a Physician Certification.
Submit Your Request
You can submit your complete request online or, print, sign, and send your request to the Pennsylvania Department of Insurance (PID).
What to Expect After You Submit a Request
Standard External Review Timeline
Expect the following timeline for your request for Independent External Review.
- Within one business day, we send your request to your health plan to confirm eligibility.
- Your health plan will notify you of your eligibility within five business days.
If you are eligible:
- Within one business day, someone will assign a review organization.
- You may submit more information for your request within 15 days of the review organization's assignment.
- The review organization will issue a decision within 45 days of its assignment.
Expedited External Review Timeline
- If your life or health is at serious risk, you can ask for an Expedited Independent External Review.
- If the review team approves your request for an expedited review, expect this timeline.
- If we find your request is not an emergency, we will review it on the standard timeline.
If you submit an expedited external review request, expect the following timeline:
- Within 24 hours of your request, we will send the request to your insurer.
- The insurer will notify you of your eligibility within 24 hours of your request. We will assign a review organization to your case within 24 hours.
- The review organization will issue a decision within 72 hours of its assignment.
- Your health plan must act on the review organization's decision within 24 hours.
Frequently Asked Questions
An independent review organization will have doctors and health pros do the review. The group selected for your case will specialize in the same area of health care as your request. This ensures that they are familiar with the type of case and treatment necessary.
These organizations are currently certified by the Pennsylvania Insurance Department to conduct reviews:
- Christopher Place Healthcare Review
- IPRO
- Keystone Peer Review Organization, Inc. (KEPRO)
- Maximus Federal Services, Inc.
- MCMC Services, LLC
- MET Healthcare Solutions
- Mitchell International, Inc. dba Medical Consultants Network, LLC (MCN)
- National Medical Reviews, Inc. (NMR)
- Physio Solutions LLC dba Medlitix
- Prest & Associates, LLC (Behavioral Health Services Only)
- ProPeer Resources, LLC
- QTC Commercial Services, LLC dba IMX Medical Management Services, Inc
- Roffe Enterprises, Inc. dba H.H.C. Group
- BHM Healthcare
- Healthcare Quality Strategies Inc (HQSI)
- Dane Street
The Pennsylvania Department of Insurance certifies that there are no conflicts of interest between the independent review organization and your insurer.
No. The independent review does not cost you anything. The insurance company pays for completed reviews.
Once the system deems your request eligible, it will assign it for independent review. You will have 15 business days to respond to the notice of the assigned independent review organization.
You must provide any extra info or medical records without delay. The independent review organization must receive this information from the source.
For a faster review, please contact the assigned organization directly.
Your health insurance company must give you an "evidence of coverage." It's a document that tells you what your plan covers. It will also have a section of exclusions.
For example, some plans exclude acupuncture; others might exclude coverage for dental procedures. These exclusions apply to all services for all members. So, a request for a non-covered service is not eligible for independent review.
For covered services, only denials based on the following are eligible for review:
- Medical necessity
- The appropriateness of the service
- The healthcare setting
- The level of care
- The effectiveness of a covered benefit
- Surprise billing and cost-sharing obligations
- The experimental or investigative nature
For the quickest submission method use:
- Online form
- Fax
You can use traditional mail. But, your request timeline cannot start until we receive your request.
Please submit any relevant medical records with your initial request to avoid delays.
Please provide any medical records that show why the service, treatment, or item should be covered.
Examples of this include:
- X-rays/MRIs/CT scans
- Test results or other diagnostic reports
- Visit summaries detailing doctors' recommendations