How to appeal a denied health insurance claim
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If your health insurer has denied a claim for service or treatment, you may be eligible to request an external review through a state program launched last year.
Why it matters: Improper claim denials can lead to medical debt and poor health outcomes for those refused critical care coverage.
- Medical debt is the most common type of consumer debt Americans face, affecting about 14 million people, who collectively owe at least $220 billion.
Driving the news: The Pennsylvania Insurance Department's new independent external review program processed more than 500 appeal requests last year, with reviewers overturning about half of the denials.
Catch up quick: The program stems from state legislation passed in 2022 to reform Pennsylvania's prior authorization process.
- Previously, residents could only request an external review through the federal government.
By the numbers: Roughly 14% of 15.5 million claims submitted by Pennsylvanians in 2023 were denied, according to state data.
- A recent KFF analysis found that HealthCare.gov insurers denied 19% of nationwide claims submitted for in-network services and 37% of claims submitted for out-of-network services in 2023.
How it works: Before you request a state review, you must first appeal with your health insurer directly.
- If your claim is still denied, you can request an appeal through the state review process online or by mail. You must request a review within four months of your denial.
- A panel of independent, third-party reviewers, such as doctors and other health care professionals, will analyze the claim and give a final determination.
- The insurer must reinstate coverage if the panel overturns the denied claim.
- A standard review can take up to two months, while an expedited review reserved for life-threatening circumstances can take up to a week.
Yes, but: The program is only available to people insured through a state health plan, the Affordable Care Act Marketplace or an employer-sponsored plan.
- People who get insurance from their employer through self-funded plans are not eligible.