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of the Commonwealth of Pennsylvania

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    Request a Review of Denied Health Insurance Claims



    Print & Send

    You can submit a request for an Independent External Review online. If you prefer to submit by mail, fax, or email, follow the three simple steps below.

    1. Download the form

    We highly recommend using a personal device to download and fill out the form. This helps ensure the security of your personal information.

    Download Form

    2. Complete the form

    After completing the form, you will be required to submit additional documentation with your application, including:

    • A copy of your insurance card. (Photos may be attached).
    • A denial letter from your health plan, known as a ‘Final Adverse Benefit Determination Letter’
    • Information about your provider
    • Any medical records or supporting materials that show why the service, treatment, or item should be covered

     

    If your life or health is at serious risk:



    You must include a Physician Certification Form to be considered for an expedited review process. This form is completed by your doctor and confirms that the service, treatment, or item is lifesaving.

    Read more about the eligibility requirements for Independent External Reviews.

    3. Send the form

    There are three ways to send your form to the PA Insurance Department.

    Fax: 717-231-7960
    Email: RA-IN-ExternalReview@pa.gov
    Mail: Pennsylvania Insurance Department 

    Attn: Bureau of Managed Care
    1311 Strawberry Square
    Harrisburg, PA 17120