A new program in the state will focus on cases in which individuals have failed to obtain payments.
The new Independent External Review program in Pennsylvania will be taking another look at health insurance claims in which policyholders felt they were incorrectly denied.
Many people feel that the current appeal process hasn’t worked for them due to its limitations.
There is already an appeal process available to health insurance customers whose claims have been denied for the cost of a medication or medical procedure. They have been able to appeal it directly with the insurer itself. However, beyond that step, there haven’t been many options available to those individuals.
The new program will make it possible to review those denied claims and provide policyholders with a new capacity to appeal against the decision made by the insurer.
The Independent External Review Program is run by the Pennsylvania Insurance Department, and it recently launched in the state. Through this program, teams of experts such as doctors and other specialists are assigned eligible cases of declined payments. These teams, contracted by the state, determine whether the insurer was correct in denying the payment for the claim.
The program’s team of experts has the power to overturn the health insurance denial from the insurer.
If the program’s independent team of reviewers determines that the insurer was wrong in its denial of a customer’s claim, the insurer is required to overturn that decision and provide coverage for the medication, service, or therapy equipment in question.
“If people believe it’s a service that they should have covered, we want to tell them to keep pushing,” said Insurance Department deputy commissioner Shannen Logue. “We want to empower the people to know that we’re here. We’ve made a really easy solution online for people so they can go ahead and request that [review].”
Pennie, Pennsylvania’s Affordable Care Act marketplace, will be taking the submissions of the cases customers feel have been wrongly denied. This includes cases from customers who purchased their health insurance through the marketplace, who receive their plans through their employers, and who purchase coverage directly through an insurer.
