Report helps consumers understand insurance

The Pennsylvania Insurance Department (PID) released its annual Transparency in Coverage (TiC) Report to continue its work to provide robust transparency into the health insurance claims process. The report puts data in the hands of Pennsylvanians to better understand claims, claim denials, and appeals rights under their fully-funded health insurance policies.

"Understanding health insurance can be hard, but through this important transparency initiative, the Shapiro Administration is making Pennsylvanians' healthcare and coverage rights clearer," said Pennsylvania Insurance Commissioner Michael Humphreys. "The important takeaway here is that a denied claim doesn't have to be the end of your story. There are internal and external appeal rights to challenge an initial coverage denial. Though the Pennsylvania marketplace outperforms the national average in terms of lower rejection rates, we still have work to do to make sure appropriate claims are submitted, processed, and paid in a way that works for Pennsylvanians."

PID's TiC report highlights important data on claims, claim denials, and appeals or health insurers selling Qualified Health Plans on Pennie. It also highlights the most common reasons for denials and provides important website links related to TiC requirements for individual and small group plans in the Commonwealth that are subject to the Affordable Care Act (ACA).

During 2024, around 500,000 Pennsylvanians enrolled in plans in the individual market (Pennsylvanians who bought their own insurance) and submitted over 20.7 million health insurance claims. Insurers denied about 3 million of those claims, resulting in a claim denial rate of 14.8%, which is 3% less than the 2024 national claim denial rate of 17.8%.

The TiC Report found that:

The percentage of claims submitted by Pennsylvanians increased 34% from 15.5 million (2023) to 20.7 million (2024);

The percentage of claims denied increased from 13.8% to 14.8%, still below the national average. The aggregated claim denial rate has been relatively stable since 2020, between 12.6% and 14.8% of all claims received;

The percentage of overturned internal appeals dropped from 48.4% to 35.7%.

Pennsylvania's internal appeal rate fell slightly. Both Pennsylvania and national consumer internal appeal rates are below 1%.

Pennsylvanians who received a denied claim should first appeal a denial through their insurer's internal appeals process. The TiC report links to Pennsylvania's largest health insurers' claim denial and appeal information pages that provide information on how to appeal claims. Claims may be denied as not medically necessary, investigational, experimental, or sometimes because incomplete or inaccurate information was submitted to the insurance company, among other reasons.

Pennsylvanians with claims decisions that remain denied following internal review can then request recourse through a PID-administered external independent review process. In an external review, the case is sent to an external independent review organization to review the claim and determine if it should be paid. PID encourages consumers to use both the internal and external appeals processes to ensure that they receive the benefits they are owed under their health plan.

Pennsylvanians with questions about their insurance, health plan, or a denied claim should visit pa.gov/consumer or call 1-866-PA-COMPLAINT (1-866-722-6675).

Consumers looking to learn more about health insurance should visit the Department's dedicated Health Insurance page.

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