State guide
Pennsylvania
Pick the kind of plan you have to see who to call first. Pennsylvania can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
Pennsylvania usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call Pennsylvania Insurance Department. See the at-a-glance box.
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Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Pennsylvania.
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Medicare
Pennsylvania Medicare Education and Decision Insight (PA MEDI) gives free counseling. Or call 1-800-MEDICARE.
The short version for Pennsylvania
Since January 2024 Pennsylvania has run its own Independent External Review: you file online with the Pennsylvania Insurance Department at no cost, and about half of the denials sent to reviewers so far have been overturned. Residents also have an unusual second ally in the Attorney General's Health Care Section, which takes complaints about insurers and medical bills. Medicaid members can get free legal help from the Pennsylvania Health Law Project.
At a glance: independent review for plans Pennsylvania regulates
- Main regulator
- Pennsylvania Insurance Department · 1-877-881-6388
- Independent review
- A state process (Independent External Review)
- Deadline to request it
- 4 months from the date of the Final Adverse Benefit Determination Letter
- Cost
- None. The insurance company pays for completed reviews.
- Decision time
- 45 days from when the review organization is assigned (most people get a final decision in under 60 days from filing); fast track: 72 hours from when the review organization is assigned
Who regulates health plans
If you get coverage through your job, ask your employer whether it is an insured plan bought from an insurance company or a self-funded benefit plan. The Pennsylvania Insurance Department says its external review does not apply to self-funded plans.
- Pennsylvania Insurance Department
Health insurance bought directly from an insurance company or through Pennie (the state marketplace), and policies that employers buy for their employees. It does not cover employers' self-funded health benefit plans.
Independent (external) review
- Process
- A state process. Run by Pennsylvania Insurance Department, which assigns a certified independent review organization.
- Where you file
- regulator
- How
- Submit the request online at pa.gov/reviewmyclaim (https://www.pa.gov/form/insurance/request-a-review-of-denied-health-insurance-claims.html), or print, sign and send the form to the Pennsylvania Insurance Department by fax, email or mail. Include your final denial letter, your insurance card and any medical records that support you. For an expedited review your doctor must also complete the Physician Certification Form.
- Which denials qualify
- Denials of covered services based on medical necessity, appropriateness, health care setting, level of care or effectiveness, denials of treatment as experimental or investigational, and surprise billing and cost-sharing disputes. Services your plan documents exclude outright are not eligible.
- Appeal to the plan first?
- Yes. The exception is when your life or health is at risk: you can request an expedited review without waiting for the internal appeal to finish.
- Published results
- From the program's start in January 2024 through an April 3, 2026 announcement, 1,353 requests were referred for external review and 655 denials were overturned (about 48%). Source
Free help in Pennsylvania
- Pennsylvania Insurance Department, Consumer Services
Answers health insurance questions, takes complaints against insurers and runs the Independent External Review for state-regulated plans.
Phone: 1-877-881-6388
- Pennsylvania Office of Attorney General, Health Care Section
Takes complaints about health insurers, providers and medical bills and steps in where consumers are unfairly denied coverage; filing with this office does not preserve your appeal deadlines, so appeal with your plan too.
Phone: 1-877-888-4877
- Pennsylvania Health Law Project
Free legal help through a statewide helpline for people having trouble getting or keeping Medicaid coverage and services.
Phone: 1-800-274-3258
Medicare and Medicaid in Pennsylvania
- Medicare counseling
- Pennsylvania Medicare Education and Decision Insight (PA MEDI) · 1-800-783-7067 . Free help with Medicare appeals.
- Medicaid agency
- Pennsylvania Department of Human Services, Medical Assistance (HealthChoices managed care)
- Fair hearing deadline
- For a managed care plan decision: 120 days from the date on the plan's complaint or grievance decision notice (the written request must be postmarked or received by then). For a decision by the Department itself, follow the deadline in your notice. Your notice states the deadline that applies to you.
- Good to know
- You must first file a complaint or grievance with your managed care plan and get its decision before asking for a fair hearing. If waiting could harm your health, ask for an early decision at 1-800-798-2339. Bureau of Hearings and Appeals: (717) 783-3950.
State laws that can help
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External review. Act 146 of 2022 created the state-run Independent External Review that began January 1, 2024, giving people in state-regulated plans a free, binding review by independent doctors.
Sources and what we could not confirm
- Request a Review If Your Health Insurance Denied a Treatment, Medication, or Service (Commonwealth of Pennsylvania)
- Independent External Review Helps Hundreds of Consumers (Pennsylvania Insurance Department, April 3, 2026)
- Pennsylvania Insurance Department Launches State External Review Process (January 8, 2024)
- Consumer Help Center (Pennsylvania Insurance Department)
- Healthcare Complaints (Pennsylvania Office of Attorney General)
- Pennsylvania Health Law Project
- PA MEDI Medicare Counseling (Pennsylvania Department of Aging)
- Complaints, Grievances, and Fair Hearings (Pennsylvania Department of Human Services, HealthChoices)
- Request a Hearing or Appeal from DHS (Commonwealth of Pennsylvania)
- Pennsylvania Consumer Assistance (Centers for Medicare & Medicaid Services)
- State External Appeals Review Processes (Centers for Medicare & Medicaid Services)
Not confirmed (5)
- The state regulators. 1-877-881-6388 is printed in the Department's 2024 release and the federal directory; the April 2026 release instead lists 1-866-722-6675 (1-866-PA-COMPLAINT), and the Consumer Help Center page shows no number
- How to file for independent review. the service page gives no mailing address or fax number for paper requests; they are on the printable form, which was not read in full
- A searchable list of past decisions. no published decisions found
- The Medicaid fair hearing deadline. the 120-day figure comes from the Department's HealthChoices template notices; the deadline for Department (non-plan) decisions and the deadline to keep benefits during an appeal were not confirmed
- State laws that help. the prior authorization and step therapy parts of Act 146 of 2022, and any state surprise billing or parity law, were not confirmed on an official page and are left out; the statute text itself was not read