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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