PENNSYLVANIA

If your insurer denies your claim, you have the right to an internal appeal.^[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

• Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your claim was denied and how you can appeal the denial.
• Collect information. In addition to the determination letter, collect all documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
• Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
• Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
• Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
• Request an expedited internal appeal, if applicable. You can request an expedited internal appeal if waiting 30 to 60 days for the requested treatment or service would jeopardize your life, health, or ability to regain function or if your health insurer has refused coverage for an admission or continued stay at a health care facility where you have not yet been discharged.^[2] If you believe you qualify for an expedited internal appeal, you should contact your insurer and ask for instruction on how to request one.
• Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

The internal appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.^[3] An expedited internal review must be completed within 72 hours of receiving the request.^[4]

During an external review, an independent third party reviews your insurer’s decision.^[5] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Pennsylvania law, you are entitled to request an external review if your insurer denies your internal appeal.

You can also request an expedited external review if:

• Your medical situation is urgent and waiting would jeopardize your life or ability to function; or
• Your health insurer has denied covered for an admission or continued stay at a health care facility where you have not been discharged.^[6]

 You can request an expedited external review at the same time that you request an expedited internal appeal.^[7]

You should submit your request for an external review to your health insurer within four months from the date that your insurer sent you the final decision.^[8] Upon receipt of your request for external review, your health insurer will assign your case to an external review organization.^[9]

Once your request is assigned to an external review organization, you have 10 days to submit supporting documentation to the external review organization. You should include documentation from your health care provider supporting why he or she prescribed the service or treatment and any other new information and documentation that you did not include with your previous request for an internal appeal.^[10] Your insurer will notify you where to send the information.^[11]

The external review process should take no more than 45 days from the date the external review organization receives your request.^[12] If you request an expedited external review, the process should take no longer than 72 hours after your request is received.^[13]

If you are a Pennsylvania resident and your claim is denied after the external review process, you can submit a complain to either the Pennsylvania Insurance Department (“Department”) or Pennsylvania Attorney General’s Office (“Office”). Both the Department and the Office handle complaints regarding health insurance companies involving claim disputes and denials of service, so you can file your complaint with either agency. You should not file a complaint with both agencies at the same time.

If you are a Pennsylvania resident and your claim is denied after the external review process, you can file a complaint with the Department.

Complaint information. A copy of the complaint packet can be found here. Your complaint should include the following information:

• The name, address, email address, and telephone number of the person making the complaint (“Complainant”);
• The name of the insured, if different than the Complainant;
• Insurance identification number;
• The type of insurance;
• The type of problem;
• The name of the insurance company;
• Policy number, claim number, and date of loss;
• The state in which the policy was sold;
• Brief description of the issue; and
• What you consider to be a fair resolution.^[14]

Supporting documents. You should submit the following supporting documents as with your complaint:

• A signed medical record release form (included with the complaint packet);
• A copy of your insurance card;
• Copies of coverage determination letters from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your doctor;
• A copy of your insurance policy; and
• All responses from your insurer.^[15]

How to submit. The complaint may be submitted online here, by fax to (717) 787-8585, or by mail to the following address:

Pennsylvania Insurance Department
Bureau of Consumer Services
Room 1209, Strawberry Square
Harrisburg, PA 17120^[16]

Upon submitting your complaint, you will receive a complaint identification number.^[17] The Department will forward a copy of your complaint to your health insurer, who has 15 days to respond. The process generally takes up to a month to complete. In many situations, the insurance company will agree to reverse or reprocess the claim.

If you are a Pennsylvania resident and your claim is denied after the external review process, you can file a complaint with the Office. A copy of the complaint packet can be found here.

Complaint information. Your complaint should include the following information:

• The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
• The name, address, email address, and telephone number of the person on whose behalf complaint is being filed, if different than the Complainant;
• The name of the insured;
• The name, address, and telephone number of insurance company;
• The policy number, group number, and type of insurance;
• The name, date of birth, and relationship to insured of the patient;
• The details of the complaint; and
• What you consider to be a fair resolution.^[18]

Supporting document. You should submit the following supporting documents with your complaint:

• A signed medical record release form (included with the complaint packet)
• A copy of your insurance card;
• Copies of determination letters from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your doctor;
• A copy of your insurance policy; and
• All responses from your insurer.^[19]

How to submit. The complaint may be submitted online here, by email to healthcare@attorneygeneral.gov, or by mail to the following address:

Office of Attorney General
Health Care Section
14^th Floor, Strawberry Square
Harrisburg, PA 17120^[20]

Once the Office receives your complaint, a Health Care Section agent will determine if the Office is the most appropriate agency to address your concern.^[21] If so, the agent will forward a copy of your complaint to your health insurer. Your insurer must respond within 15 business days.^[22] After reviewing all documentation, the agent will send you a decision.  You should expect the process to take a minimum of 30 days.^[23] In many cases, the insurance company will agree to reverse or reprocess the claim.

If the Health Care Section is not the appropriate agency to handle your complaint, the agent will forward it to the appropriate agency and advise you where it has been sent.^[24] If your complaint involves an allegation of fraud or possible criminal activity on the part of the insurer, your complaint may be sent to the Insurance Fraud Section or the Criminal Prosecutions Section or another state or federal agency, depending on the facts of your case.

You can contact the Pennsylvania Attorney General’s Office, Health Care Section at (717) 705-6938 or (877) 888-4877. The Office is open from 8:30 a.m. to 5:00 p.m. Monday through Friday.

You can contact the Pennsylvania Insurance Department at (877) 881-6388. The Department is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.