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    Pennsylvania Insurance Department

    Request a Review of Denied Health Insurance Claims

    If your health plan has denied covering a service, treatment, or item, you may be eligible to request an Independent External Review. This review allows you to submit information detailing why a service, treatment, or item should be covered and have your case reviewed by an independent third party.


    If the review organization determines the disputed request should be covered, your health plan will be required to do so. Independent review decisions are final and binding.

    Submit Online Request
    Print & Send

    If Your Life or Health is at Serious Risk


    For urgent requests, please select an Expedited Independent External Review in your application. 


    Submit this request as soon as you receive the initial notification from your health plan that your service, treatment, or item has been denied. You will still need to file an internal appeal with your health plan. Unlike the standard process, DO NOT WAIT for the internal appeal process to be completed.


    You must also submit a Physician Certification Form confirming that the service, treatment, or item is lifesaving.

    Required Documents

    What Information Do I Need to Request a Review?

    • A denial letter from your health plan, known as a ‘Final Adverse Benefit Determination Letter’. This is the letter you received from your health plan after you requested an internal review.
    • Your insurance card
    • Any medical records or supporting materials that show why the service, treatment, or item should be covered

    Eligibility

    What type of insurance do you have?

    This process only applies to insurance provided by your employer when your employer purchases it from a licensed insurance company (the coverage is not governed by ERISA), that you have purchased from Pennie®, or directly from an insurance company.

    Have you requested an internal appeal with your health plan?

    Before you can request an Independent External Review, you must have already gone through an internal appeal with your health plan. The internal appeal process can differ by health plan, so you will need to reach out to your insurer for information.


    Once your health plan has completed an internal review, they will issue you a ‘Final Adverse Benefit Determination Letter.’ If your service, treatment, or item is still denied, then you can begin the Independent External Review process.

    How long has it been?

    You must submit a request for an Independent External Review within four months from the date of the 'Final Adverse Benefit Determination Letter.'

    After You Submit a Request

    If you submit a standard internal review request, expect the following timeline:

    • Within one business day: we will forward your request to your health plan to confirm your eligibility.
    • Within five business days: your health plan will notify of determined eligibility

    If you are determined eligible:

    • Within one business day of confirming eligibility: you will be informed of the Independent Review Organization assigned to your case.
    • Within 15 business days of an Independent Review Organization being assigned: you must submit any additional information that will support your need for the service, treatment, or item.

    If you submit an expedited internal review request, expect the following timeline:

    • Within 24 hours of your request (including weekend and holidays): we will send the request to your insurer.
    • Within 24 hours of the health plan being sent to the insurer: you will be notified of your request’s eligibility. An Independent Review Organization will then be assigned to your case within 24 hours.
    • Within 72 hours of an Independent Review Organized being assigned: a decision will be issued by the Independent Review Organization.
    • Within 24 hours of the Independent Review Organization decision: your health plan must implement the decision.

    Frequently Asked Questions

    Submit Request

    You can submit your request online or Print, Sign, and Send your request to PA Department of Insurance (PID).

    Submit Online

    Submit a Request for an Independent External Review entirely online. The process is simple and we'll walk you through each step along the way.

    Submit Online

    Print & Send

    Prefer to Print, Sign and Send? You can print, sign, and send the form directly to the PA Insurance Department via fax, email or Mail.

    Print & Send