What is external review?
Independent external review is a second look at certain final denials after internal appeal. The Pennsylvania Insurance Department (PID) receives your request, confirms eligibility, and assigns a certified independent review organization (IRO) that is not your insurance company.
For eligible cases, the IRO decision is final and binding on you and your plan. There is no fee for consumers to submit a standard external review request.
General overview: Appeals roadmap. Complete Pennsylvania internal appeals first unless an urgent exception applies.
Who can use Pennsylvania review?
PID external review generally applies when:
- You have fully insured commercial coverage regulated by PID (many Pennie plans, individual policies, and employer-purchased commercial insurance—not self-funded ERISA)
- The dispute involves medical necessity, appropriateness, level of care, effectiveness, experimental/investigational treatment, or No Surprises Act cost-sharing issues covered by Act 146
- You exhausted internal appeal—or qualify for deemed exhaustion, waiver, or simultaneous expedited review
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare and Medicare Advantage (federal Medicare appeals)
- Medicaid managed care (DHS fair hearing instead)
- Pure complaints or grievances routed under separate Act 146 complaint/grievance articles
Deadlines & exhaustion
Four-month filing window
File a written external review request with PID within four months after you receive notice of an adverse benefit determination or final adverse benefit determination (Act 146 § 2164.5). PID advises requesting review within four months of your final denial letter.
Exhaust internal appeal first
Complete internal appeal unless:
- The insurer waives internal appeal (§ 2164.4(d))
- You qualify for deemed exhaustion (30-day rule, procedural failures)
- You file simultaneous expedited internal and external review in urgent cases (§ 2164.4(b))
Additional information to the IRO
After PID assigns an IRO, you may submit additional written information within 15 business days of the assignment notice. The IRO may accept late submissions at its discretion (§ 2164.5(d)).
How to file
- Complete internal appeal and obtain a final denial when required.
- Gather the denial letter, appeal correspondence, signed HIPAA authorization (if required), and medical records.
- Submit your request through PID's online portal: Request a review of denied health insurance claims.
- PID forwards the request to your insurer for a 5-business-day preliminary eligibility review, then assigns an IRO if eligible.
Toolkit: Health coverage & external review process · Consumer help: 877-881-6388
Links hub: Pennsylvania external appeals links.
How long it takes
- Standard review: IRO decision within 45 days of IRO assignment; most cases complete in under 60 days from PID receipt
- Expedited review: IRO decision within 72 hours of assignment when approved; plan must implement within 24 hours of the decision
- Eligibility screening: insurer preliminary review within 5 business days; PID assigns IRO within 1 business day after eligibility
Is the decision binding?
For eligible medical disputes, the IRO decision is binding on you and your health plan. If the IRO overturns the denial, the plan must provide coverage or payment consistent with the decision.
External review decisions are generally final for that dispute. If you disagree after an uphold, ask PID what limited remedies may exist or consult an attorney.
Medicaid & Medicare
Medicaid: MCO complaint/grievance, then state fair hearing with DHS—not PID commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; free counseling through Pennsylvania APPRISE.
More: Medicaid managed care · Medicare appeals.