In Pennsylvania, external review of a denied health-plan claim is administered by Pennsylvania Insurance Department. Pennsylvania launched its own state external-review program effective January 1, 2024 (Act 146 of 2022); before that it used the federal process. After internal appeals are exhausted, an independent reviewer decides, and the decision binds the plan. Expedited review is available for urgent cases.
How external review works in Pennsylvania
Pennsylvania runs its own external review program, administered by Pennsylvania Insurance Department. Pennsylvania launched its own state external-review program effective January 1, 2024 (Act 146 of 2022); before that it used the federal process.
After you exhaust the plan's internal appeals, an independent reviewer outside the plan examines the denial and the medical record. The decision binds the plan — if it overturns the denial, the plan must cover the service. Expedited review is available when waiting would jeopardize your health.
Plan type still governs
Deadlines and eligibility
In Pennsylvania the request must be filed within four months of the final internal denial, and the Insurance Department assigns the certified independent review organization.
State external review applies to fully insured and ACA-marketplace plans, after the plan's internal appeals are exhausted. The reviewer's decision is binding on the plan. Confirm the exact current window on your denial notice.
Frequently asked
Does Pennsylvania run its own external review?
Does Pennsylvania's external review cover an ERISA plan?
Primary sources: 45 CFR 147.136 (internal claims, appeals & external review); HealthCare.gov — external review process. General information, not legal or medical advice — confirm against the governing rule for the plan type.
When the appeal has to be written, and cited
Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.