Pennsylvania health insurance appeal rights

Denied in Pennsylvania? Since 2024 the state runs its own Independent External Review Program. After your internal appeal, an independent reviewer outside your insurer can overturn the denial — free. Here’s how it works and the four-month deadline to watch.

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How appeals work in Pennsylvania

Pennsylvania gives you a two-step path after a denial — and since 2024 it runs its own Independent External Review Program. First you appeal to your health plan (the internal appeal). When the plan issues its Final Adverse Benefit Determination, you can request an Independent External Review through the Pennsylvania Insurance Department (PID) — an independent medical review outside your insurer, whose decision is binding on your plan.

External review applies when a plan denies care as not medically necessary, experimental or investigational, or otherwise clinically inappropriate. (Self-funded employer plans use the federal external review process instead — your denial letter will say which applies.)

Step 1 — your internal appeal

Appeal to your plan in writing first, with your denial notice and supporting records. Federal rules generally give you at least 180 days from the denial — check your own notice. Ask for an expedited appeal if your situation is urgent.

Step 2 — Pennsylvania’s Independent External Review

After you receive the Final Adverse Benefit Determination, submit your request to PID. Within about five business days PID tells you whether your denial is eligible; most consumers get a final decision in under 60 days. An expedited review for urgent cases moves in days, with the reviewer’s decision within 72 hours of assignment. The review is free.

Pennsylvania’s program is new but already effective: in its early months the Insurance Department reported that independent reviewers overturned insurers and delivered the requested care in a large share of cases. That is history, not a prediction about your case — but it shows that challenging a denial is often worth it.

Where to file and get help

• PA Independent External Review — submit online at iro.insurance.pa.gov.
• Pennsylvania Insurance Department — consumer services 1-877-881-6388.

Putting it together

Read the denial, file your internal appeal, then request the Independent External Review after the Final Adverse Benefit Determination. Our step-by-step guide covers each stage, external review explains independent review generally, and the appeal-deadline guide helps you track dates. In another state? See New York or California appeal rights.