New to helping someone in Pennsylvania?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork.
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Pennie/Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
Pennsylvania law gives you an internal appeal with the insurer first in most cases, then a right to independent external review through an IRO assigned by the Pennsylvania Insurance Department (PID).
For steps that work in every state, read these general guides first, then return here for Pennsylvania rules:
What is different in Pennsylvania?
- Pennie: Pennsylvania runs its own Marketplace at Pennie.com. Major 2026 carriers include Highmark, Independence Blue Cross, UPMC, Geisinger, Capital Blue Cross, Ambetter, and Oscar (availability varies by county).
- Prior authorization (Act 146): Effective January 1, 2024 — 72-hour / 24-hour urgent, 15-day standard, 24–72 hour Rx; no PA for emergencies; licensed specialist reviewers (Act 146 of 2022, 40 P.S. § 991.2155).
- Internal appeals: Act 146 § 2164 — federal-aligned process; typically 180 days to file; 30/60-day decisions; deemed exhaustion after 30 days without a decision.
- External review: File with PID within four months (PID independent external review); IRO decision within 45 days standard / 72 hours expedited; binding and free for consumers.
- Medicaid: MCO complaint/grievance first, then DHS fair hearing (120 days from MCO decision in many programs)—separate from commercial IRO review.
Who is in charge of your plan?
- PID: External review, consumer help — insurance.pa.gov. Consumer hotline: 877-881-6388
- U.S. Department of Labor: Many self-funded employer plans.
- DHS Bureau of Hearings and Appeals: Medicaid fair hearings — Hearings and appeals (DHS)
- CMS / APPRISE:Medicare counseling through Pennsylvania's State Health Insurance Assistance Program.
After appeals are exhausted, see Regulator complaints.