Health insurance or Medicaid said no in Pennsylvania? Deadlines and free help

In Pennsylvania, your health plan is regulated by Pennsylvania Insurance Department (PID), if it is a state-regulated plan.

Pennsylvania runs its own independent review of denials: Independent External Review. You generally have 4 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

Medical Assistance

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (Pennie) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in Pennsylvania?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months
Hearing deadline
30 days
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – Pennie
90 days

All the details →

How long do I have? Deadline calculator

How do I know which plan type I have?

  • Pennsylvania Insurance Department (PID) · 1-877-881-6388 · Complaint form
    Health insurance policies and HMOs/managed care plans sold in Pennsylvania (individual, small group, and job-based plans that are not self-funded). Its Bureau of Health Coverage Access, Administration, and Appeals runs the complaint, grievance and external review programs.

How to tell which agency regulates your plan

The Insurance Department's external review covers insurance provided by your employer, plans bought on Pennie, and plans bought directly from an insurance company. If you have Medicaid or CHIP, you use your managed care plan's external grievance process instead. If your job-based plan is self-funded, federal rules apply (contact the U.S. Department of Labor, EBSA).

Step 1: Appeal to your plan in Pennsylvania

What it is called: Internal appeal of an adverse benefit determination (and, for other problems, a complaint)

Insurers must run an internal appeal process that follows the federal rules (Public Health Service Act section 2719). For problems that are not medical-necessity denials (for example coverage, operations or a provider), insurers must run a two-level complaint process: the first level is decided within 30 days and the second level within 45 days. You then have 15 days from receiving the second-level decision to appeal to the Insurance Department.

Law: 40 P.S. 991.2141, 991.2142, 991.2164 (Act 146 of 2022)

All the details →

Step 2: Outside review in Pennsylvania

Independent External Review

Deadline to ask: 4 months.

All the details →

Urgent care in Pennsylvania: faster decisions

Outside review

If waiting could seriously harm your life, health or ability to regain maximum function, or you got emergency care and have not been discharged, you can ask for expedited review. Your doctor must complete the Physician Certification Form. The review organization decides within 72 hours, and your plan must act on the decision within 24 hours.

Law: 40 P.S. 991.2164.1-991.2164.14 (Act 146 of 2022, effective January 1, 2024)

Medicaid

In HealthChoices, if your doctor or dentist says waiting could harm your health, call DHS at 1-800-798-2339, email RA-PWCGFHteam@pa.gov or fax your request to 717-772-6328; your doctor must fax a signed letter to 717-772-6328 or testify. DHS holds a phone hearing and decides within 3 business days.

Law: 55 Pa. Code 275.3, 275.4

Marketplace

If you need health services right away and a delay could seriously jeopardize your health, you can ask for an expedited (faster) appeal.

Law: 45 CFR 155.500-155.555; 1 Pa. Code Part II, Chapters 31-35; Pennie Appeal Request Form (07/2024)

Complaints about your plan in Pennsylvania

For other problems with your insurer, file a complaint or ask a question through the Insurance Department's Consumer Services Online (CSO) portal, linked from the Department's 'Need Help?' page, or call 1-877-881-6388. After an insurer's complaint or administrative-denial decision, you have 15 days from receiving it to appeal to the Insurance Department.

Law: 40 P.S. 991.2142

www.pa.gov

Medicaid (Medical Assistance (Medicaid); HealthChoices managed care) denials in Pennsylvania

Who holds the hearing: DHS Bureau of Hearings and Appeals (BHA).

Hearing deadline: 30 days

All the details →

Marketplace decisions in Pennsylvania

Marketplace

Pennie · 1-844-844-8040

Appeal deadline

90 days

The date of the final eligibility determination

How to appeal

Fill out the Pennie Appeal Request Form and send it by email (Appeals@pennie.com), mail (Pennie Appeals, PO Box 2008, Birmingham, AL 35203) or fax (717-232-2226). Pennie first checks that the appeal is valid and offers an informal resolution; if not resolved, a hearing examiner decides after a formal hearing.

Form

Pennie Appeal Request Form

Faster appeal

If you need health services right away and a delay could seriously jeopardize your health, you can ask for an expedited (faster) appeal.

Coverage while you appeal

If you appeal a redetermination that changes or removes your financial help, you can ask on the form to keep your financial help while the appeal is reviewed. You must keep paying premiums, and you may have to pay back extra premium tax credit at tax time.

Law: 45 CFR 155.500-155.555; 1 Pa. Code Part II, Chapters 31-35; Pennie Appeal Request Form (07/2024)

Other rights in Pennsylvania

How fast an insurer must decide a prior approval

Unless federal law requires otherwise, insurers must decide urgent prior authorization requests within 72 hours (24 hours for ongoing urgent care asked for at least 24 hours before it ends) and other requests within 15 days. Prescription drug and step therapy requests: 24 hours if urgent, otherwise within 2 business days but no more than 72 hours.

Law: 40 P.S. 991.2155(i) (Act 146 of 2022)

Medicaid managed care external grievance

HealthChoices and CHIP managed care members have a separate external grievance process. It must be filed with the plan within 15 days of the internal grievance denial; an independent reviewer decides within 60 days whether the service was medically necessary, and the plan must provide or pay for the service if it wins, even if the plan goes to court.

Law: 40 P.S. 991.2162

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in Pennsylvania and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in Pennsylvania

Good to know in Pennsylvania

  • Since January 1, 2024, the Pennsylvania Insurance Department runs its own Independent External Review program instead of the federal process.

    Law: Act 146 of 2022, 40 P.S. 991.2164.1 et seq

  • Pennsylvania gives only 30 days from the date of the written notice to appeal most Medical Assistance decisions, shorter than the federal maximum of 90 days.

    Law: 55 Pa. Code 275.3(b)(1)

  • HealthChoices members can ask for both an external grievance review and a DHS Fair Hearing on the same grievance decision.

Changes in 2024–2026

January 1, 2024: Act 146 of 2022 took effect. The Insurance Department took over the state external review program (with online filing), set prior authorization time limits, step therapy rules and a provider portal, and moved managed care oversight to the Insurance Department.

Law: 40 P.S. 991.2101 et seq

Questions about appeals in Pennsylvania

How long do I have to appeal a health insurance denial in Pennsylvania?

State law follows the federal internal appeal rules. Use the deadline on your denial notice; federal rules give at least 180 days. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in Pennsylvania?

Independent External Review. Apply online, or print the form and send it with your denial letter, a copy of your insurance card, information about your provider and any medical records by email (RA-IN-ExternalReview@pa.gov), fax (717-231-7960) or mail (Pennsylvania Insurance Department, Attn: Bureau of Managed Care, 1311 Strawberry Square, Harrisburg, PA 17120). After you are found eligible you can send more information to the assigned review organization within 15 business days.

Is outside review free in Pennsylvania?

External review is free. You cannot be charged a fee to ask for it; the insurer pays the review organization.

How long do I have to ask for a Medicaid fair hearing in Pennsylvania?

30 days. The date of the written notice of the decision or action

Can I keep my Medicaid benefits while I appeal in Pennsylvania?

If DHS plans to reduce or end your Medical Assistance, the advance notice gives a date 10 calendar days after the notice was mailed. If your appeal is received or postmarked by that date, your benefits continue until the hearing decision unless you say you do not want them continued.

How do I appeal a Marketplace decision in Pennsylvania?

Fill out the Pennie Appeal Request Form and send it by email (Appeals@pennie.com), mail (Pennie Appeals, PO Box 2008, Birmingham, AL 35203) or fax (717-232-2226). Pennie first checks that the appeal is valid and offers an informal resolution; if not resolved, a hearing examiner decides after a formal hearing.

Not about a denied claim?

Nearby states

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