If your health plan denies care in Pennsylvania, appeal. Start with the internal appeal described in your denial letter (you usually have 180 days). If the plan still says no, Pennsylvania's Independent External Review program - free, run by the state Insurance Department at pa.gov/reviewmyclaim or 1-877-881-6388 - assigns an independent physician reviewer whose decision binds the insurer, and it overturned 50% of the denials it reviewed in its first year. You have 4 months after the final denial to file. Self-funded employer plans follow the federal route instead (externalappeal.cms.gov, 1-888-866-6205). Medicaid members can get free legal help from the Pennsylvania Health Law Project at 1-800-274-3258, and Medicare members get free counseling from PA MEDI at 1-800-783-7067.
A denial letter is written to sound final. "Not medically necessary." "Not a covered benefit." Most people read one, sigh, and either pay the bill or skip the care.
The numbers say that is the wrong move. In the marketplace plans the federal government tracks, about 1 in 5 in-network claims was denied in 2023, and fewer than 1 in 100 of those denials was ever appealed. But when Pennsylvanians carried a denial all the way to the state's new Independent External Review in its first year, half of them won. The appeal system works for the people who use it, and almost nobody uses it.
You have more power here than the letter suggests. This is the Pennsylvania playbook: what to do in the first week, which appeal path matches your plan, and the phone numbers that connect you to free help.
Which appeal path is yours?
The right process depends on who regulates your plan, so sort this first.
- You bought the plan yourself - through Pennie (Pennsylvania's official marketplace) or straight from an insurer. Your plan is state-regulated, and the Pennsylvania path below is yours.
- Insurance through work, fully insured. Your employer buys a policy from a carrier - in our corner of the state that is often Independence Blue Cross, out west and centrally it is often Highmark. Also state-regulated, and the Pennsylvania path applies.
- Insurance through work, self-funded. Your employer pays the claims itself and hires a carrier just to administer them. Most large, multi-state employers do this. These plans follow federal rules, so skip ahead to the self-funded section.
- Medicaid (Medical Assistance) or CHIP. You have your own path - grievances and fair hearings - plus free lawyers who help. See the Medicaid and CHIP section.
- Medicare. Medicare runs its own appeal levels, and Pennsylvania staffs free counselors to walk you through them. See the Medicare section.
Not sure whether your work plan is fully insured or self-funded? Ask HR that question in those words, or look in your Summary Plan Description. A card that says "administered by" a carrier is a hint that the plan may be self-funded. The federal benefits advisors at 1-866-444-3272 can help you sort it.
Step 1: Read the denial letter and start a file
The letter must tell you why the claim was denied and how to appeal, though the useful parts are sometimes buried pages deep. Read all of it, and keep it.
- Find the reason. Many denials are administrative - a mistyped code, a missing record, a name that did not match. Those often die when the provider corrects and resubmits, so call the billing office first. The denials worth a full appeal are the judgment calls: "not medically necessary," "experimental," or a service the plan says is excluded.
- Find your deadlines. Internal appeals usually allow 180 days from the denial notice; your letter states the number that applies to you. Put it on the calendar now.
- Request your claim file. You have a right to the record your insurer used to make the decision, including the reviewer's notes. Seeing it often reveals the weak point in the denial. ProPublica publishes a free Claim File Helper that builds the request letter for you.
- Keep a written log. Every call gets a line: date, the name of the person you spoke with, what was said, what was promised. Save every letter and explanation of benefits.
- Tell your doctor early. The ordering clinician's records and letter carry the most weight in everything that follows.
Step 2: File the internal appeal
Before anyone outside the company can review your case, the insurer gets a chance to reverse itself. Some plans require 1 level of internal appeal, some 2. It feels like asking the referee to re-watch their own call, and sometimes it works - reviewers correct plenty of errors at this stage.
What makes an internal appeal strong is specificity. The denial gave a reason; your appeal answers that reason directly. A letter of medical necessity from your doctor that ties your history, your records, and the clinical guidelines to the denied service does more than any form letter. Your doctor can also request a peer-to-peer review - a direct call with the insurer's physician - which resolves many denials on its own.
If waiting would put your health at risk, say so and ask for an expedited appeal. Urgent cases move in days instead of weeks, and in urgent situations you can often run the internal and external appeals at the same time.
If the final answer is still no, the plan must send you a Final Adverse Benefit Determination letter. Keep it. That letter is your ticket to the step most people never take.
Step 3: Ask Pennsylvania for an independent external review
Since January 1, 2024, Pennsylvania has run its own Independent External Review program under Act 146 of 2022, and it may be the most underused right in Pennsylvania health care. Once your internal appeals are exhausted, the state Insurance Department assigns your case to an independent review organization - licensed physicians with no tie to your insurer - and their decision is binding. If they overturn the denial, your plan must cover the care.
The results from year 1: 517 Pennsylvanians filed, and 259 won - a 50.1% overturn rate. Half of the people who took this step got the denial reversed.
The practical details:
- It is free. There is no fee to file.
- You have 4 months from the date on your Final Adverse Benefit Determination letter.
- File online at pa.gov/reviewmyclaim, or by email, fax, or mail. Call the Insurance Department's consumer line at 1-877-881-6388 if you want a human to walk you through it.
- The department confirms eligibility within about 5 days. You then get 15 business days to send the reviewer anything you want seen - medical records, your doctor's letter, a personal statement. Use that window; it is where your story gets told.
- The reviewer decides within 45 days of assignment, and most people have a final answer within 60 days of filing. An expedited track exists when waiting would endanger you - your doctor certifies the urgency and the review moves in days.
One honest note: external review fits denials that involve medical judgment - medical necessity, experimental designations, and similar calls. A service that your contract truly excludes is generally not eligible, which is another reason to read the denial reason closely in step 1.
What if your employer plan is self-funded?
Self-funded plans follow federal law rather than Pennsylvania's, but the shape is the same: internal appeal first, then an independent external review that the plan must obey. Your denial letter names the external review process that applies to you.
- Many self-funded plans use the federal external review process: file at externalappeal.cms.gov or call 1-888-866-6205. It is free, and urgent requests can be started right on that phone line.
- The Department of Labor's benefits advisors at 1-866-444-3272 answer questions about employer plans, help you understand your appeal rights, and can step in when a plan ignores its own deadlines.
Medicaid and CHIP: grievances and fair hearings
If you have Medical Assistance through a HealthChoices plan and a service is denied, reduced, or stopped, your denial notice explains how to file a grievance or complaint with the plan and how to request a fair hearing from the Department of Human Services, where a judge who does not work for the plan hears your case.
Move fast. Appealing within days of the notice can keep your services running while the case is decided, and the deadlines are shorter than commercial insurance.
You do not have to do this alone, and you do not have to pay anyone. The Pennsylvania Health Law Project gives free legal help to people with Medicaid problems - they advise, and they represent people at grievances and fair hearings. Call 1-800-274-3258 (Monday, Wednesday, and Friday, 8 a.m. to 8 p.m.). For CHIP questions, the state line is 1-800-986-5437.
Medicare
Medicare has its own appeal levels, and the paperwork is its own project. Pennsylvania's answer is PA MEDI - free, unbiased Medicare counselors at every Area Agency on Aging who help with denials, appeals, billing problems, and plan questions. Call 1-800-783-7067, weekdays 8 a.m. to 5 p.m. They sell nothing; they only help.
A word on mental health denials
Denials land hardest here, in the middle of a crisis, and the pattern is well documented. Parity laws require plans to cover mental health and substance-use care on the same terms as physical care, and Pennsylvania regulators have fined insurers in recent years for falling short of that standard. Inpatient psychiatric and substance-use denials are among the categories external reviewers overturn most often.
If you are fighting one of these:
- Care comes before paperwork. In a crisis, call or text 988 any time. The appeal can wait until the person is safe; deadlines are measured in months, not hours.
- Use the expedited tracks. A physician's certification that waiting is dangerous moves an appeal from weeks to days at every level.
- Borrow a template. The nonprofit Cover My Mental Health publishes free letter templates for medical-necessity appeals. ProPublica's reporting on a Highmark external appeal shows what a winning file looks like: records from every provider, the doctors' letters, and a plain accounting of what happened.
- Get help carrying it. A family member or friend can be your authorized representative and run the whole appeal for you.
How we help when insurance says no
Our members' visits are never the thing being denied - membership covers our time directly, which is the point of the hybrid model. Denials show up around the edges: an MRI, a medication, a specialist procedure, a hospital stay billed through your benefits.
When one lands, bring it to us early. We pull your records into an organized file, write the letter of medical necessity, request the peer-to-peer call, and handle prior authorizations before care so fewer denials happen in the first place. You should not have to learn insurance law while you are sick. Having a doctor who fights the paperwork with you is part of what primary care is supposed to be.
Key Takeaways
- About 1 in 5 in-network claims gets denied, and fewer than 1 in 100 denials is appealed. The people who appeal win often.
- Pennsylvania's Independent External Review overturned 50% of the denials it reviewed in its first year. It is free, binding on the insurer, and filed at pa.gov/reviewmyclaim within 4 months of the final denial.
- The denial letter is the map: it holds the reason, your deadlines, and which external process applies to your plan.
- Numbers to save: Insurance Department 1-877-881-6388 (state-regulated plans), PHLP 1-800-274-3258 (free Medicaid legal help), PA MEDI 1-800-783-7067 (Medicare), federal benefits advisors 1-866-444-3272 (self-funded employer plans), and 988 in any mental health crisis.
- Urgent cases move on expedited tracks measured in days. Ask, and have your doctor certify the urgency.
- Bring your doctor in early. A specific letter of medical necessity is the strongest page in the file.
Sources and official pages
These are the official pages behind every number above, so you always land on the current rules.
- Pennsylvania Independent External Review and the department's first-year results
- Pennsylvania Insurance Department Consumer Help Center - 1-877-881-6388
- Pennie, Pennsylvania's official health insurance marketplace
- Federal external review and the filing portal - 1-888-866-6205
- U.S. Department of Labor, Ask EBSA - 1-866-444-3272
- Pennsylvania Medicaid and CHIP
- Pennsylvania Health Law Project - 1-800-274-3258
- PA MEDI Medicare counseling - 1-800-783-7067
- KFF, Claims Denials and Appeals in ACA Marketplace Plans - the denial and appeal rates cited above
- ProPublica's external appeal guide and Claim File Helper
- Cover My Mental Health - free appeal letter templates
Programs, phone numbers, deadlines, and eligibility rules change over time, and your plan documents control your specific rights. This guide is education, not legal advice; for legal questions about your plan, talk with a qualified attorney or one of the free programs above. In a medical emergency call 911, and in a mental health crisis call or text 988.
Related at Fishtown Medicine
- Insurance & benefits guide: the hybrid model - how membership and your insurance work side by side
- HSA and FSA for direct primary care - paying for membership with pre-tax dollars
- Philadelphia city health resources - cooling and warming centers, utility help, and the city numbers worth saving
Frequently Asked Questions
Common Questions
Ready when you are
Dr. Ash reads every intake himself, and answers questions personally - usually within a few hours.
