Claim denial rate remains lower than 2022 national rate ​​

Harrisburg, PA - The Pennsylvanian Insurance Department (PID) today announced that the 2024 Transparency in Coverage (TiC) Report is now available online, including helpful information for consumers on what to do if their insurance company denies their claim. The report also outlines data on claims, claim denials, and appeals information for health insurers doing business in the Commonwealth.

"Our Department is pleased to announce the availability of this important transparency initiative," said Pennsylvania Insurance Commissioner Michael Humphreys. "This report contains valuable information consumers can use if their insurance company denies their claim. Most importantly, though, we want Pennsylvanians to know that the option to appeal a denied claim is available and that the odds of reversing the decision are in favor of the consumer."

Pennsylvania's TiC report highlights important data on claims, claim denials, and appeals information for 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 2023, Pennsylvanians enrolled in individual market plans submitted over 15.5 million health insurance claims. Insurers denied around 2.1 million of those claims, resulting in a claim denial rate of just below 14 percent, which is lower than the 2022 national claim denial rate of 18 percent.

Any member of an ACA-compliant plan may appeal a denied claim when it is denied as not medically necessary, investigational, experimental or cosmetic. 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 who received a denied claim can first appeal the denial with their insurer. If they are still dissatisfied with the decision, they can then request an appeal through an external independent review process. In this instance, the case will be sent to an external independent review organization to review the claim and determine if it should be paid.

Pennsylvanians with questions about their insurance, health plan, or a denied claim should contact PID's Consumer Services Bureau online or at 1-877-881-6388. Consumers looking to learn more about health insurance should visit the Department's dedicated Health Insurance page.