Pennsylvania Insurance Denial Report

The worst health insurers in Pennsylvania
by claim denial rate

Pennsylvania averages a 18.4% denial rate — 0.7 points below the national average. About 640,000 claims are denied annually.

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18.4%
Pennsylvania avg denial rate
19.1%
National average
640,000
Annual denials in state
>80%
Appeals overturned when filed

Health insurance denials in Pennsylvania

In Pennsylvania, the health insurance claim denial rate stands at 18.4%, slightly below the national average of 19.1%. This statistic translates to approximately 640,000 denied claims each year, highlighting a significant issue that can affect countless patients seeking necessary medical care. These denials can create barriers to accessing treatments, medications, and services that individuals rely on for their health and well-being. Understanding this landscape is crucial for patients navigating the complexities of health insurance in the state.

Worst insurers in Pennsylvania by denial rate

Source: CMS Marketplace Transparency Report 2023. In-network ACA marketplace claims only.

1

UnitedHealthcare

32.5% denial rate

UHC denies 32.5% of claims — 13.4 points above the national average. Their appeal overturn rate is 57%.

Specialty Medications: 43% deniedGLP-1 Medications: 41% deniedMRI / CT Scans: 35% denied
Full UHC denial report →
2

Ambetter from Centene

21.3% denial rate

Ambetter denies 21.3% of claims — 2.2 points above the national average. Their appeal overturn rate is 53%.

GLP-1 Medications: 36% deniedSpecialty Medications: 28% deniedMental Health: 24% denied
Full Ambetter denial report →
3

Aetna (CVS Health)

17.2% denial rate

Aetna denies 17.2% of claims — 1.9 points below the national average. Their appeal overturn rate is 65%.

GLP-1 Medications: 28% deniedSpecialty Medications: 22% deniedMental Health: 18% denied
Full Aetna denial report →

Your rights as a Pennsylvania insurance patient

Pennsylvania offers specific protections for patients facing claim denials. Patients have the right to an internal appeal, where they can contest the decision directly with their insurer. If the internal appeal is unsuccessful, they can request an external Independent Medical Review, providing an unbiased assessment of their case. The Pennsylvania Insurance Department serves as the regulatory body overseeing these processes, and patients can file complaints free of charge. This action can compel insurers to reconsider their decisions, empowering patients to advocate for their rights and access the care they need.

Pennsylvania Insurance Department
https://www.insurance.pa.gov

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How to appeal a denial in Pennsylvania

  1. 1
    Request the denial in writing
    Ask your insurer for the specific clinical criteria and coverage policy they used to deny you. They are legally required to provide it within 30 days.
  2. 2
    File your internal appeal
    Send a written appeal to your insurer within 180 days. Cite your doctor's clinical documentation, relevant medical guidelines, and Pennsylvania insurance law. A well-written appeal citing specific laws wins over 80% of the time.
  3. 3
    Escalate to the state if denied again
    If your internal appeal is denied, file an Independent Medical Review (IMR) with the Pennsylvania Insurance Department. This is free and decided by independent clinicians. Their decision is often binding.
  4. 4
    Use disputes.health to generate your letter
    Our agents generate a clinic-grade appeal letter in under 15 minutes — citing your state's laws, relevant medical guidelines, and your specific situation. We then submit it to your insurer for you.
How to appeal a denial →GLP-1 denial guide →Mental health denial guide →All public resources →

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