A new initiative in Pennsylvania is aiming to provide individuals with another avenue to appeal insurance denials for medical procedures or medications. The Independent Review Program, launched by the Pennsylvania Insurance Department this month, offers a fresh opportunity for individuals who have been denied coverage by their health insurers.
Under this program, eligible cases are assigned to teams comprised of doctors, specialists, and other experts who assess whether the insurance denial was justified. If the independent review teams, contracted by the state, find that a patient was wrongly denied coverage, the health insurers are required to overturn the denial and provide coverage for the service, medication, or therapy equipment in question.
Shannen Logue, deputy commissioner of the state Insurance Department, emphasized the importance of empowering individuals to challenge insurance denials, stating, “If people believe it’s a service that they should have covered, we want to tell them to keep pushing.” The program offers a user-friendly online solution for individuals to request a review.
The Independent Review Program accepts cases from residents with health plans purchased through Pennie, the state’s Affordable Care Act marketplace, as well as those who obtain insurance directly from a company and employees covered by employer-sponsored health plans.
Upon submission, eligibility for review is determined within five days. Subsequently, the program assigns the case to a contracted independent review organization and team. A 15-day “pause period” allows both the patient and the review team to gather additional relevant documents and information.
Logue explained that the review teams have 45 days to analyze the case, with most individuals receiving a decision within 60 days. Additionally, an expedited process is available for cases involving urgent life-threatening or serious health risks, ensuring timely decisions when necessary.
The inception of this review program stems from state legislation signed into law by former Gov. Tom Wolf in 2022, which aimed to enhance state-based review services and support for individuals navigating their health insurance needs.
