INSURANCE
Filing Health
APPEALS
Has your insurance company
denied your medical claim or
failed to pay your claim the way
you think it should? You may be
able to resolve the issue by filing
an appeal.
By law, health insurance companies are required to
have procedures in place to address concerns from
policyholders. The appeals process is used if you
receive an adverse benefit determination, that is,
when your insurance company denies a benefit or
does not make full payment on a benefit that you and
your doctor believe you need. This can happen for
many reasons, including:
• The benefit isn’t covered by your health insurance
plan;
• You received the service(s) from an out-of-network
health provider or facility;
• The service is not medically necessary;
• The service is specifically excluded from your
policy;
• The service is a covered service at an in-network
provider, but you and your insurer disagree about
how much you should pay; or
• You are no longer eligible for coverage under that
health insurance plan.
If you believe you’ve received an adverse benefit
determination that you don’t think is right, make
sure to read your explanation of benefits before
contacting your health insurance plan. You will
receive an explanation of benefits every time your
insurance company receives a bill for you,
and it lists the services you received and
how much the insurance company will pay
on your behalf for those services. This
document may help you understand why
you are receiving a charge or why a certain
service wasn’t covered. It will also explain
how to file an appeal with the company.
If your insurance company denies your
request for a service that you and your doctor
believe you need, you may appeal this adverse benefit
determination. Adverse benefit determinations can
be reviewed by a health insurance company in an
internal appeal process. If you are still unsatisfied
with the results after completing the internal appeal,
you may appeal for an external review performed
by an independent party. If you are unable to request
the review or need assistance, you have the right to
appoint a representative, such as a family member or
your health care provider.
How exactly does the appeal
process work? Let’s look a little
closer.
Internal Appeal Process
You may file an
appeal with your
health insurance
plan if you feel that
you wrongfully
received an adverse
benefit determination.
Insurance companies must
make their initial decision
regarding whether or not a service you received or
seek to receive is covered within:
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Some of the language used in this guide may be unfamiliar, so we’ve
included definitions for bolded terms at the end of this guide.
The appeals process is used when
your insurance company denies
a benefit or does not make full
payment on a benefit that you and
your doctor believe you need.
The appeals process is used when
your insurance company denies
a benefit or does not make full
payment on a benefit that you and
your doctor believe you need.
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• 15 days of the request for a service requiring
pre-authorization;
• 30 days for a service that was already received;
• 72 hours for urgent cases, or sooner if medically
necessary.
From there, if the company makes an initial decision
to deny coverage on a medically necessary health care
service or to deny access to a service that requires
pre-authorization, determines that a service wasn’t
medically necessary, or determines that you are not
eligible to receive coverage by the plan, you may
want to consider filing an internal appeal.
An appeal must be filed within six months of
receiving an adverse benefit determination. Health
insurance companies must make accommodations if
you have a disability or language barrier.
your representative) and your insurance company
throughout the claims and appeal process, including
the date, time, the name of the person you spoke
with, and the content of the conversation. Keep
original documents and send copies if you are
providing the company with supporting documents.
If you have questions about how to file or what
to include with your appeal, you may contact the
Pennsylvania Insurance Department.
Insurance companies must reach a decision on an
appeal within a certain time frame. Generally, if you
are appealing a pre-service claim (for example, you
were denied pre-authorization), the appeal must
be completed within 30 days. If you have already
received the treatment, the internal appeal must be
completed within 60 days. If your medical situation
is urgent, you will be able to get a decision sooner.
We’ll discuss these expedited appeals a little later in
this guide.
After your insurance company
completes your internal appeal, you
will receive a written determination
explaining the company’s reasons for
the decision. If you are unsatisfied
with the outcome, you may request
an external review performed by an
independent party, although some
companies may require a second
internal appeal before you are
able to request an external
review. Your insurance company
must explain how to begin
this process in their written
determination of your internal
appeal.
External Review Process
Your health insurance
company must give you four
months from the date you
received the decision on your
internal appeal to file a request for
an external review. External
Make sure to maintain a detailed log
of communications between you and
your insurance company throughout
the claims and appeal process.
Make sure to maintain a detailed log
of communications between you and
your insurance company throughout
the claims and appeal process.
The insurance company must give each
appeal a full and fair review, meaning
you can submit new or expanded
information to support your claim.
The company must also provide
you or your representative with
copies of everything it has
related to your claim. Your
insurance company must
give you and/or your
representative(s) proper
time to review and respond to
the company’s supporting
evidence before a decision is made.
Make sure to maintain a detailed log
of communications between you (or
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review is not available for all adverse
benefit determinations. External
review is available for adverse benefit
determinations such as whether your
care is medically necessary, where
you receive care, what types of care
are available to you, and rescissions
of coverage. If your issue involves
something else, external review is not
available to you.
External reviews are assigned to an independent
review organization (IRO). Health insurance
companies are required to contract with at least
three IROs and assign them to cases on a random or
rotating basis. IROs are independent, do not work for
your insurance company, and
cannot receive financial
incentives to side with
one party over
another.
You have 10
business days to
submit supporting
documents to the
IRO. Like other
stages in the review
process, it is very
important to include
documentation from
your health care provider so
the IRO may gain an understanding
of why the particular service was recommended.
If any documents are submitted late, the IRO may
accept the information, but it isn’t required to do
so. Your insurance company will submit to the IRO
information it considered when making the adverse
benefit determination.
During the external review, the IRO will review the
claim from the beginning and has no obligation
to uphold your insurance company’s previous
decisions. IROs employ legal and medical experts
to consider documents submitted by you and your
insurance company as well as your medical records,
recommendations from your health care provider,
reports from independent health care providers in
a similar field, the terms of your insurance policy,
medical practice guidelines, and clinical review criteria
developed by your insurance company, if applicable.
The IRO will reach a decision and provide written
notice to you and your insurance company within 45
days of receiving the request for external review,
unless the review is expedited. This decision
will include an explanation of what the IRO
decided, as well as references to evidence
that supports the final outcome. If the
IRO decides in your favor, your
insurance company is obligated to pay
for the services in question. The
decision of the IRO is final and binding
against both you and the insurance
company.
Expedited Review Processes
In certain circumstances, both internal appeals
and external reviews can be completed on a much
shorter timeline. Those circumstances are when a
covered individual’s life, health, or ability to return
to maximum function would be jeopardized by the
timeline of the standard review process. You may
also request an expedited external review in cases
where your insurance company refuses coverage
for admission to or continued stay at a health care
facility if you have not yet been discharged.
In urgent situations, you can request an external
review even if you haven’t completed all of the health
plan’s internal appeals processes. You may file an
internal appeal and an external review request at the
same time.
The decision of the IRO (independent
review organization) is final and
binding against both you and the
insurance company.
The decision of the IRO (independent
review organization) is final and
binding against both you and the
insurance company.
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behalf. The EOB may be attached to a check or
statement of electronic payment.
External Review
A review by an IRO of a plan’s decision to deny
coverage for or payment of a service. If the plan
denies an internal appeal, an external review can
be requested. An external review either upholds
the plan’s decision or overturns all or some of the
plan’s decision. The plan and covered person must
accept this decision.
Independent Review Organization
An organization that determines whether a health
insurance company was correct to refuse to pay for
health care services for a covered individual based
on the coverage provided by the policy and the
medical judgment of health care professionals. IROs
do not work for the insurance companies and can
fairly decide whether the insurance company or the
covered individual is correct.
Internal Appeal
A review by an insurance company of its own
adverse benefit determination, triggered by a
covered individual who believes that their claim
should have been paid in whole or in part.
Medical Necessity/Medically Necessary
Generally speaking, services or supplies your
health are provider determines are needed for
prevention, diagnosis or treatment of a patient’s
illness or injury or other medical condition that
meet generally accepted medical standards and are
clinically appropriate for the patient. Your health
plan may have a more specific definition.
Rescission of Coverage
Rescission of Coverage is the retroactive cancellation
of a health insurance policy. Rescission of Coverage
is prohibited except in cases of fraud or intentional
misrepresentation of a fact relevant to the
individual’s enrollment.
Questions can be submitted at
www.insurance.pa.gov at the
“Ask a Question or File a Complaint”
link on our homepage.
After you submit your question, a representative
from our Consumer Services Bureau will be in touch
to help. Consumers can also reach the department by
phone at 1-877-881-6388.
Defined Terms
Adverse Benefit Determination
A determination by a health insurance company
that includes a denial, reduction, termination,
or failure to make either full or partial payment
for a benefit, regardless of the reason for the
determination.
Explanation of Benefits
A statement sent by a health insurance company
to covered individuals explaining what medical
treatments and/or services were paid for on their
Aside from the timeframe, the expedited review
process follows most of the same procedural
requirements as a standard review. If you or your
representative cannot appear in person given the
timeline, the review will take place over the phone.
You or your representative should be ready to present
as much information as possible given the abbreviated
timeline.
Expedited reviews must be completed within 72 hours
of the request but can be completed more quickly if
the medical condition requires more immediate action.
This final decision can be delivered verbally but must
be followed by a written notice within 48 hours.
If You Need Help
The Pennsylvania Insurance Department understands
that the appeal processes may be confusing for
consumers, but the department is here to help.
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Sample letter to request an internal appeal
Your Name
Your Address
Date
Address of the Health Plan’s Appeal Department
Re: Name of Insured
Plan ID#:
Claim #:
To Whom It May Concern:
I am writing to request a review of your denial of the claim for treatment or services provided
by name of provider on date provided.
The reason for denial was listed as (reason listed for denial), but I have reviewed my policy and
believe treatment or service should be covered.
Here is where you may provide more detailed information about the
situation. Write short, factual statements. Do not include emotional
wording.
If you are including documents, include a list of what you are
sending here.
If you need additional information, I can be reached at telephone number and/or e-mail address.
I look forward to receiving your response as soon as possible.
Sincerely,
Signature
Typed Name
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Sample letter to request an external review
Your Name
Your Address
Date
Address of the Health Plan’s Appeal Department
Re: Name of Insured
Plan ID#:
Claim #:
To Whom It May Concern:
I am writing to request an external review by an independent review organization (IRO) of the
final internal adverse benefit determination I received on date. I have included a copy of that
determination with this request.
I filed my request for an internal appeal on date in response to the denial of coverage for
treatment or service provided by name of provider on date provided. The medical review upheld the
original decision.
Here is where you may provide more detailed information about the
situation. Write short, factual statements. Do not include emotional
wording.
If you are including documents, include a list of what you are
sending here.
If you need additional information, I can be reached at telephone number and/or e-mail address.
I look forward to receiving your response as soon as possible.
Sincerely,
Signature
Typed Name
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Questions?
For more information on
auto insurance, visit:
www.insurance.pa.gov
and click “Health”
under Coverage
or
call the department at
1-877-881-6388
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