Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.707 - External grievance process

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  plan shall establish and maintain an external grievance process by which an
				  enrollee, or a health care provider with the written consent of the enrollee,
				  may request an external review of a denial of a second level grievance
				  following receipt of the second level grievance review decision.
(b) The external grievance process shall
				  adhere to the following standards:
(1) An
				  enrollee, the enrollee's representative or the health care provider who filed
				  the grievance shall have 15 days from receipt of the second level grievance
				  review decision to file a request for an external review with the plan. If the
				  request for an external grievance is being filed by a health care provider, the
				  health care provider shall provide the name of the enrollee involved and a copy
				  of the enrollee's written consent for the health care provider to file the
				  grievance.
(2) Within 5 business
				  days of receiving the external grievance from the enrollee or a health care
				  provider filing a grievance with enrollee consent, the plan shall notify the
				  Department, the enrollee and the health care provider if the health care
				  provider has filed the grievance with enrollee consent, and a CRE that
				  conducted the internal grievance review that a request for an external
				  grievance review has been filed.
(3) The plan's notification to the Department
				  shall include a request for assignment of a CRE.
(4) Along with notification and the request
				  for assignment of a CRE, and the information in paragraph (5), the plan shall
				  provide the Department with the name, title and phone numbers of both a primary
				  and alternative external grievance coordinator. One of these individuals shall
				  be available to the Department so that expeditious communication may be had
				  regarding the assignment of a CRE both for the purpose of performing external
				  grievance reviews and of tracking the status of such reviews.
(5) The plan's request to the Department for
				  assignment of a CRE shall include the following:
(i) The enrollee's name, address and
				  telephone number.
(ii) If the
				  request for an external grievance is being filed by a health care provider,
				  identifying information for that provider, and a copy of the enrollee's written
				  consent to the health care provider to file the grievance.
(iii) The name of the plan.
(iv) The enrollee's plan identification
				  number.
(v) The enrollee's appeal
				  from the second level grievance review decision.
(vi) A copy of the decision of the second
				  level review committee.
(vii)
				  Correspondence from the plan relating to the matter in question.
(viii) Other reasonably necessary supporting
				  documentation, which may include UR criteria, technology assessments, care
				  notes, information submitted by clinicians regarding the enrollee's health
				  status as it relates to the matter being reviewed, opinions from specialists in
				  a same or similar specialty or peer reviewers and information submitted by the
				  enrollee, the enrollee's representative and the treating health care
				  providers.
(ix) If the external
				  grievance is being requested by a health care provider, verification that the
				  plan and the health care provider have both established escrow accounts in the
				  amount of half the anticipated cost of the review.
(6) Within 15 days of receipt of the request
				  for an external grievance review, the plan shall forward to the CRE assigned to
				  perform the external grievance review the written documentation regarding the
				  denial, including the following:
(i) The
				  decision.
(ii) All reasonably
				  necessary supporting information.
(iii) A summary of applicable
				  issues.
(iv) The contractual
				  language supporting the denial including the plan's definition of "medical
				  necessity" used in the internal grievance reviews.
(7) Within the same 15-day period as provided
				  by paragraph (6), the plan shall provide the enrollee, the enrollee's
				  representative, or the health care provider if the health care provider filed
				  the grievance with consent, with the list of documents being forwarded to the
				  CRE for the external review.
(8)
				  The enrollee, the enrollee's representative, or the health care provider if the
				  health care provider filed the grievance with enrollee consent, within 15 days
				  of receipt of notice that the request for an external grievance review was
				  filed with the plan, may supply additional information to the CRE for
				  consideration in the external review but shall simultaneously provide copies of
				  the information to the plan so that the plan has an opportunity to consider the
				  additional information.