Pennsylvania took its external review back from Washington in 2024

Pennsylvania's own program, new since 01/01/2024

Until 2024, a Pennsylvanian whose insurer upheld a denial went to the HHS-administered federal review. Act 146 of 2022 moved that work to the state: since 01/01/2024 the Pennsylvania Insurance Department runs the Independent External Review itself, through its Bureau of Managed Care, and consumers file through a portal the Commonwealth built for it. Scope is fully insured commercial coverage — insurance an employer purchases, a Pennie plan, or a policy bought directly.

• The eligible grounds run wider than medical necessity alone: appropriateness, care setting, level of care, effectiveness, experimental or investigational determinations, and also surprise-billing and cost-sharing disputes.
• A plan exclusion — a service the contract never covers — falls outside the process entirely.
• Medicare denials are routed to Medicare.gov; Medicaid and CHIP denials go to the managed-care organization's External Grievance Review.
• The independent reviewer's decision is final and binding on the insurer.

Four months, counted from the Final Adverse Benefit Determination Letter

Pennsylvania expresses the window in calendar months, not a day count: the request must be made within four months of the date on the Final Adverse Benefit Determination Letter — the notice the insurer sends when it upholds the denial at the close of the internal appeal. There is no separate, shorter provider clock. A provider acting as the member's authorized representative files on the same member-signed application, under the same four months.

One practical trap: PID warns that a mailed request does not start the clock until the Department receives it. When the four months is close, the portal or email is the safer channel.

Expedited cases break the sequencing. Where life or health is at serious risk, PID's instruction is not to wait for the internal appeal to conclude before requesting external review.

How to file with the Insurance Department

1. 1

   Finish the internal appeal — unless it's urgent

   The four-month clock runs from the Final Adverse Benefit Determination Letter. For a case where life or health is at serious risk, PID tells applicants not to wait for the internal appeal to finish.

2. 2

   Assemble what the application requires

   The Final Adverse Benefit Determination Letter, the member's insurance card, and the records supporting the request. An expedited request additionally requires PID's Physician Certification form, completed by the treating physician.

3. 3

   Have the member sign, and name the representative in writing

   The application is member-centric: the member or legal guardian signs it, and a provider, family member, or attorney is designated as representative by written authorization on the form.

4. 4

   Send it to PID through one of four channels

   The Department's online request service on pa.gov is the primary route, and the retired iro.insurance.pa.gov portal address forwards straight to it; there is also email to [email protected], fax to 717-231-7960, and mail to the PA Insurance Department, Attn: Bureau of Managed Care, 1311 Strawberry Square, Harrisburg, PA 17120.

5. 5

   Calendar the assignment notice

   Once the case is assigned, you have 15 business days from receiving that notice to get additional records in front of the reviewer.

Who assigns the reviewer — and the clocks

The carrier does not pick the reviewer. PID determines eligibility with the insurer, then assigns a certified independent review organization from its own list within one business day of that finding — one that specializes in the same area of care, with PID certifying no conflict of interest between the IRO and the insurer. The certified roster is published on the portal: 16 organizations at this writing, among them IPRO, KEPRO, Maximus Federal Services, MCMC, Dane Street, National Medical Reviews, BHM Healthcare, HQSI, and Prest & Associates for behavioral health only.

Pennsylvania splits the notice duty in a way worth knowing about. PID assigns the reviewer within one business day, but the insurer is the party that tells the consumer whether the case was found eligible, within five business days.

• Standard: PID sends the request to the plan within one business day; the insurer notifies eligibility within five business days; the IRO is assigned within one business day; the IRO decides within 45 days of assignment.
• PID reports that most consumers get a final decision in under 60 days from the date it receives the request.
• Expedited: the request goes to the insurer within 24 hours, eligibility within 24 hours, IRO assigned within 24 hours, decision within 72 hours of assignment — and the plan must act on that decision within 24 hours.
• The review costs the consumer nothing; the insurance company pays for completed reviews.

What Pennsylvania's published results show

PID has reported outcomes since the program opened, in unusually specific terms. In the first year, 2024, 259 Pennsylvanians won appeals they had lost with their insurer, and 50.1% of eligible reviews were overturned. Counting from launch through the Department's April 3, 2026 report, PID had referred 1,353 eligible cases to independent reviewers, and 655 denials were overturned — close to 48%.

What PID publishes is the eligible-and-referred count, not total intake, so that rate describes cases that cleared eligibility. Clearing eligibility is the first thing to check on any Pennsylvania case: the right plan type, a Final Adverse Benefit Determination Letter in hand, and a ground that isn't a flat contract exclusion.

For Pennsylvania providers and billers

Act 146 is Pennsylvania's prior-authorization reform as well as its external-review law, and the Insurance Department has stated publicly how it reads the operative section. In Insurance Department Notice 2024-11 (54 Pa.B. 4407, July 27, 2024), PID set out three requirements under 40 P.S. § 991.2155: subsection (b) requires every insurer to post, in an accessible location on its website, the list of services requiring prior authorization; subsection (d) bars any non-administrative prior-auth denial unless the insurer's reviewer is a licensed provider with training, knowledge or experience in the same or similar specialty that typically manages the service, or consults with one who is; subsection (e) applies that same same-or-similar-specialty standard to the peer-to-peer reviewer. PID cited 40 P.S. §§ 991.2181(d) and 991.2182 as its enforcement authority.

So if the denial names a reviewer outside the specialty that manages the service, or the peer-to-peer went to someone who doesn't practice it, that is a Pennsylvania-specific point to put in writing — with the citation — well before the case reaches an IRO.

A physician, with two narrow exceptions

Pennsylvania's Act 68, at 40 P.S. 991.2152, requires that a utilization review resulting in a denial of payment for a health care service be made by a licensed physician meeting the qualifications the Act sets out.

The exceptions are deliberately narrow. A licensed psychologist may review behavioral health services within their scope of practice where their clinical experience is sufficient, and a licensed dentist may review dental services on the same basis — and each such use must be approved by the department as part of the utilization review entity's certification. Anything outside those two categories has to be a physician.