If Your Life or Health is at Serious Risk
For urgent requests, please select an Expedited Independent External Review in your application. Submit a request as soon as you receive the initial notification from your health plan. You will still need to file an internal appeal with your health insurance. Unlike the standard process, DO NOT WAIT for the internal appeal process to be completed.
You must submit a Physician Certification Form to confirm the service, treatment, or item is lifesaving.
Required Documents
- A ‘Final Adverse Benefit Determination Letter,’ a denial letter from your health plan
- Your insurance card
- Any medical records or materials that show why the request should be covered
For Expedited Independent External Reviews, your doctor must also complete a Physician Certification.
Eligibility
What type of insurance do you have?
This process applies to insurance that has been:
- Provided by your employer
- Purchased from Pennie®
- Purchased directly from an insurance company
If you have Medicaid or CHIP, you will instead want to use the External Grievance Review Process by contacting your Managed Care Organization. If you have Medicare, you can visit Medicare.gov for more information on filing an appeal.
Have you requested an internal appeal with your health plan?
Before you request a review, you must go through an internal appeal with your health plan. The internal appeal process can differ by health plan. You will need to reach out to your insurer for information.
Your health plan will then issue a ‘Final Adverse Benefit Determination Letter.’ If your request is still denied, you can begin the Independent External Review process.
How long has it been?
You must request a review within four months from the date of the ‘Final Adverse Benefit Determination Letter.’
After You Submit a Request
Standard External Review Timeline
Expect the following timeline for your request for Independent External Review.
- Within one business day: your request is sent to your health plan to confirm eligibility.
- Within five business days: your health plan will notify of determined eligibility.
If you are eligible:
- Within one business day: a review organization is assigned.
- Within 15 business days of the review organization assignment: you may submit extra information for your request.
- Within 45 days of review organization assignment: a decision will be issued.
Expedited External Review Timeline
If your life or health is at serious risk, you can request an Expedited Independent External Review. If your request for an expedited review is approved, expect the following timeline. If your request is determined to not be an emergency, your submission will be reviewed on the standard timeline.
If you submit an expedited external review request, expect the following timeline:
- Within 24 hours of your request: we will send the request to your insurer.
- Within 24 hours of the request to the insurer: you will be notified of your eligibility. A review organization will be assigned to your case within 24 hours.
- Within 72 hours of review organization assignment: a decision will be issued.
- Within 24 hours of review organization decision: your health plan must put in place the decision.
Frequently Asked Questions
The group of doctors and health care professionals employed by an independent review organization will perform the review. The group selected for your case will specialize in the same area of health care as your request. This ensures they are familiar with the type of case and treatment necessary. These organizations are currently certified with the Pennsylvania Insurance Department to conduct reviews:
- Christopher Place Healthcare Review
- IPRO
- Keystone Peer Review Organization, Inc. (KEPRO)
- Maximus Federal Services, Inc.
- MCMC Services, LLC
- MET Healthcare Solutions
- Mitchell International, Inc. dba Medical Consultants Network, LLC (MCN)
- National Medical Reviews, Inc. (NMR)
- Physio Solutions LLC dba Medlitix
- Prest & Associates, LLC (Behavioral Health Services Only)
- ProPeer Resources, LLC
- QTC Commercial Services, LLC dba IMX Medical Management Services, Inc
- Roffe Enterprises, Inc. dba H.H.C. Group
- BHM Healthcare
- Healthcare Quality Strategies Inc (HQSI)
- Dane Street
The Pennsylvania Department of Insurance certifies there are no conflicts of interest between the independent review organization and your insurer.
No. The independent review does not cost you anything. The insurance company pays for completed reviews.
Once your request has been deemed eligible and assigned for independent review, you will have 15 business days from when you receive the notice informing you of the independent review organization assigned to your request to provide any extra information or relevant medical records directly to the independent review group. This information must be sent directly to the independent review organization.
If you have additional information to submit for an expedited independent review, please contact the organization assigned to your independent external review directly.
Your health insurance company is required to give you an “evidence of coverage,” which is a document that tells you what is covered by your specific plan. It will also have a section of exclusions. For example, some plans exclude acupuncture; others might exclude coverage for dental procedures. Because these exclusions apply to all such services for all members, a request for a non-covered service is not eligible for independent review. For covered services, only denials based on the following are eligible for independent review:
- Medical necessity
- The appropriateness of the service
- The health care setting
- The level of care
- The effectiveness of a covered benefit
- Surprise billing and cost-sharing obligations
- The experimental or investigation nature
Using the online form, email, or fax are the quickest way to submit your expedited review request. You can use traditional mail, but your request timeline cannot begin until your request is received.
You can submit any relevant medical records and supporting materials with your initial request to avoid delays.
Include any medical records or supporting materials that help show why the service, treatment, or item should be covered. Examples of this include:
- X-rays/MRIs/CT Scans
- Test results or other diagnostic reports
- Visit summaries detailing doctor recommendations
