HARRISBURG, PA — The Pennsylvania Insurance Department (PID) has released the 2024 Transparency in Coverage (TiC) Report, a significant resource aimed at empowering consumers with crucial information regarding insurance claims and denials. This report, now accessible online, provides detailed data on claims processing, denials, and the appeals process for health insurers operating within the Commonwealth.
Pennsylvania Insurance Commissioner Michael Humphreys emphasized the importance of this initiative, stating, “Our Department is pleased to announce the availability of this important transparency initiative. This report contains valuable information consumers can use if their insurance company denies their claim.” He further noted that appealing a denied claim is a viable option for consumers, with favorable odds of reversing such decisions.
The TiC Report offers a comprehensive overview of claims data for health insurers providing Qualified Health Plans through Pennie, Pennsylvania’s state-based health insurance marketplace. It outlines the most common reasons for claim denials and includes essential links related to TiC requirements for individual and small group plans under the Affordable Care Act (ACA).
In 2023, individuals enrolled in Pennsylvania’s individual market plans submitted over 15.5 million health insurance claims. Of these, approximately 2.1 million were denied, resulting in a claim denial rate of just under 14 percent, notably lower than the national average of 18 percent recorded in 2022. This data highlights the comparative efficiency of Pennsylvania’s insurers in processing claims.
The report underscores the right of any member of an ACA-compliant plan to appeal denied claims, particularly those deemed not medically necessary, investigational, experimental, or cosmetic. PID advises consumers to utilize both internal and external appeals processes to secure entitled benefits. Initially, consumers can appeal directly to their insurer. If the outcome remains unsatisfactory, they may escalate the case to an external independent review process, which will assess the claim and determine its validity.
This transparency effort by the PID is designed to enhance consumer understanding of the insurance landscape, encouraging proactive engagement in the appeals process and ensuring equitable access to healthcare services. The 2024 TiC Report is a pivotal tool for consumers navigating the complexities of insurance claims, reinforcing the PID’s commitment to fairness and accountability in health insurance practices across Pennsylvania.
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