Pennsylvania external review
Pennsylvania launched its own state-run external review program on January 1, 2024 (Act 146 of 2022), replacing the federal process — and it publishes results: 50.1% of appealed denials were overturned in the program's first full year. Filing happens through a purpose-built online portal, it's free, and the decision is final and binding on your insurer.
Deadlines and decision timelines
- Your filing window: 120 days from the final internal denial.
- Standard review decided in: 45 days from IRO assignment; most requests decided in under 60 days end to end
- Expedited review decided in: 72 hours — your life or health is at serious risk; requires a physician certification form
- Cost to you: None — the insurer pays for the review
How to file, step by step
- Exhaust your insurer's internal appeal. You need the Final Adverse Benefit Determination Letter — that letter is your ticket into external review.
- File through the state portal. Submit at pa.gov/reviewmyclaim (the PID external review portal). Fax, email, and mail are also accepted, but mailing delays the clock until receipt.
- Eligibility check, then your evidence window. PID determines eligibility within 5 business days, and you then get 15 business days to add supporting records — physician letters, clinical notes, guidelines.
- The IRO decides. An assigned Independent Review Organization issues a decision within 45 days (72 hours expedited). If it rules for you, your plan is required to cover the service.
Who can use it
- Commercial coverage from an employer, a plan purchased through Pennie (Pennsylvania's ACA exchange), or a plan bought directly from an insurer.
- Not eligible: self-funded (ERISA) employer plans — those use the federal external review. Medicare, Medicaid, and CHIP have their own separate appeal processes.
What to know
- Four months from the date of the Final Adverse Benefit Determination Letter to file.
- Use the online portal if you can — mailed requests don't start the clock until they arrive.
- Independent review decisions are final and binding on the health plan.
- PID's published results: 53% of eligible reviews overturned in the program's first six months, and 50.1% across the first full year (2024).
Denial data from plans operating in Pennsylvania
Pennsylvania external review FAQ
How often do Pennsylvania external reviews succeed?
In the program's first full year (2024), 50.1% of appealed denials were overturned per the Pennsylvania Insurance Department — 259 Pennsylvanians won coverage their insurer had denied.
Does Pennsylvania's external review cost anything?
No. The review costs you nothing — the insurance company pays for completed reviews.
How do I file?
Online at pa.gov/reviewmyclaim after you receive your Final Adverse Benefit Determination Letter. You can also file by fax, email, or mail, but mailed requests delay the start of review until received.
How long does a decision take?
Eligibility is determined within 5 business days, you get 15 business days to submit additional records, and the review organization decides within 45 days of assignment — most requests finish in under 60 days. Urgent cases with physician certification are decided within 72 hours.
What if my employer plan is self-funded?
Self-funded (ERISA) employer plans aren't covered by Pennsylvania's program — those use the federal external review process. Your denial letter should say which process applies.
Primary sources
- PID — Request a review of a denied service
- PID — first-year results (50.1% overturned)
- PID — program launch announcement (Act 146)