reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter G - HMOS › OPERATIONAL STANDARDS › Section 9.654 - HMO external quality assurance assessment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Within 18 months after enrollment of the
					 first enrollee, and every 3 years thereafter unless otherwise required by the
					 Department, an HMO shall have an external quality assurance assessment
					 conducted using an EQRO acceptable to the Department. Department personnel may
					 participate in the external quality assurance assessment. The following also
					 apply to external quality assurance assessments:
(1) The Department will perform a site visit
					 of the HMO 12 months after the issuance of a certificate of authority whether
					 or not the HMO has enrollees, to ensure that the HMO is complying with the
					 requirements of the HMO Act, Act 68 and this chapter.
(2) If the HMO has no enrollees more than 18
					 months from the issuance of a certificate of authority the Department will
					 peform a site visit to ensure that the HMO is in compliance with the HMO Act,
					 Act 68 and this chapter.
(3) If,
					 following the site visit in paragraph (2), the HMO has no enrollees for the
					 next 6 months, the HMO may not begin to enroll members until the Department
					 performs an additional site visit.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.671 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
This subchapter is applicable to managed care plans,
					 including HMOs and gatekeeper PPOs, and subcontractors of managed care plans,
					 including IDSs, for services provided to enrollees.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.672 - Emergency services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall
				  utilize the definition of "emergency service" in section 2102 of the act
				  (40
				  P. S. §
											991.2102) in administering
				  benefits, adjudicating claims and processing complaints and
				  grievances.
(b) A plan may not deny
				  any claim for emergency services on the basis that the enrollee did not receive
				  permission, prior approval, or referral prior to seeking emergency
				  service.
(c) A plan shall apply the
				  prudent layperson standard to the enrollee's presenting symptoms and services
				  provided in adjudicating related claims for emergency services.
(d) Coverage for emergency services provided
				  during the period of the emergency, shall include evaluation, testing, and if
				  necessary, stabilization of the condition of the enrollee, emergency
				  transportation and related emergency care provided by a licensed ambulance
				  service. Use of an ambulance as transportation to an emergency facility for a
				  condition that does not satisfy the definition of "emergency service" does not
				  constitute an emergency service and does not require coverage as an emergency
				  service.
(e) A plan may not require
				  an enrollee to utilize any particular emergency transportation services
				  organization or a participating emergency transportation services organization
				  for emergency care.
(f) The
				  emergency health care provider shall notify the enrollee's managed care plan of
				  the provision of emergency services and the condition of the
				  enrollee.
(g) If the enrollee is
				  admitted to a hospital or other health care facility, the emergency health care
				  provider shall notify the enrollee's managed care plan of the emergency
				  services delivered within 48 hours or on the next business day, whichever is
				  later. An exception to this requirement will be made where the medical
				  condition of the patient precludes the provider from accurately determining the
				  identity of the enrollee's managed care plan within 48 hours of
				  admission.
(h) If the enrollee is
				  not admitted to a hospital or other health care facility, the claim for
				  reimbursement for emergency services provided shall serve as notice to the
				  enrollee's managed care plan of the emergency services provided by the
				  emergency health care provider.
This section cited in 28 Pa. Code §
												9.651 (relating to HMO provision
						and coverage of basic health services to
						enrollees).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.673 - Plan provision of prescription drug benefits to enrollees

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan providing prescription drug
				  benefit coverage to enrollees, either as a basic benefit or through the
				  purchase of a rider or additional benefit package, and using a drug formulary
				  which lists the plan's preferred therapeutic drugs, shall clearly disclose in
				  its marketing material and enrollee literature that restrictions in drug
				  availability may result from use of a formulary.
(b) An enrollee, a prospective enrollee, or
				  health care provider may make a written or verbal inquiry to a plan asking
				  whether a specific drug is on the plan's formulary. The plan shall respond in
				  writing to the request within 30 days from the date of its receipt of the
				  request. If the drug that is the subject of the inquiry is not on the plan's
				  formulary, the plan's response shall include a listing of the drugs in the same
				  class that are on the formulary or instruct the enrollee how to access the
				  formulary.
(c) A plan utilizing a
				  drug formulary shall have a written policy that includes an exception process
				  by which a health care provider may prescribe and obtain coverage for the
				  enrollee for specific drugs, drugs used for an off-label purpose, biologicals
				  and medications not included in the formulary for prescription drugs or
				  biologicals when the formulary's equivalent has been ineffective in the
				  treatment of the enrollee's disease or if the drug causes or is reasonably
				  expected to cause adverse or harmful reactions to the enrollee. The following
				  standards apply when an exception is sought:
(1) Exception requests are to be considered
				  requests for prospective UR decisions and shall be processed within 2-business
				  days.
(2) If the exception is
				  granted, the plan shall provide coverage in the amount disclosed by the plan
				  for the nonformulary alternative under section 2136(a)(1) of the act
				  (40
				  P. S. §
												991.2136(a)(1)).
(3) A letter denying the request shall
				  include the basis and clinical rationale for the denial and instructions on how
				  to file a complaint or a grievance.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.674 - Quality assurance standards

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  plan shall have an ongoing quality assurance program that includes review,
				  analysis and assessment of the access, availability and provision of health
				  care services. The quality assurance program shall provide for a mechanism
				  allowing feedback to be reviewed and used for continuous quality improvement
				  programs and initiatives by the plan.
(b) The quality assurance program shall meet
				  the following standards:
(1) The plan shall
				  maintain a written description of its quality assurance program outlining its
				  structure and content.
(2) The plan
				  shall document all quality assurance activities and quality improvement
				  accomplishments.
(3) The activities
				  of the plan's quality assurance program shall be overseen by a quality
				  assurance committee that includes plan participating health care providers in
				  active clinical practice.
(4) The
				  plan's quality assurance structures and processes shall be clearly defined,
				  with responsibility assigned to appropriate individuals.
(5) The plan shall demonstrate dedication of
				  adequate resources, in terms of appropriately trained and experienced
				  personnel, analytic capabilities and data resources for the operation of the
				  quality assurance program.
(6) The
				  plan shall ensure that all participating health care providers maintain current
				  and comprehensive medical records which conform to standard medical
				  practice.
(7) The plan's review of
				  quality shall include consideration of clinical aspects of care, access,
				  availability and continuity of care.
(8) The plan's quality assurance program
				  shall have mechanisms that provide for the sharing of results with health care
				  providers in an educational format to solicit input and promote continuous
				  improvement.
(9) The plan shall
				  provide to the Department a description of the annual quality assurance work
				  plan, or schedule of activities, which includes the objectives, scope and
				  planned projects or activities for the year.
(10) The plan shall present a report of the
				  plan's quality assurance activities documenting studies undertaken, evaluation
				  of results, subsequent actions recommended and implemented, and aggregate data
				  annually to the plan's board of directors, and shall provide a copy of the
				  report to the Department.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.675 - Delegation of medical management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  plan may contract with an entity for the performance of medical management
				  relating to the delivery of health care services to enrollees. The plan shall
				  be responsible for assuring that the medical management contract meets the
				  requirements of all applicable laws. The plan shall submit the medical
				  management contract to the Department for review and approval. The Department
				  will review a medical management contract within 45 days of receipt of the
				  contract. If the Department does not approve or disapprove a contract within 45
				  days of receipt, the plan may use the contract and it shall be presumed to meet
				  the requirements of all applicable laws. If, at any time, the Department finds
				  that a contract is in violation of law, the plan shall correct the violation.
				  Reimbursement information submitted to the Department under this paragraph may
				  not be disclosed or produced for inspection or copying to a person other than
				  the Secretary or the Secretary's representatives without the consent of the
				  plan which provided the information, unless otherwise ordered by a
				  court.
(b) If the contractor is to
				  perform UR, the contractor shall be certified in accordance with Subchapter K
				  (relating to CREs).
(c) To secure
				  Department approval, a medical management contract shall include the following:
(1) Reimbursement methods being used to
				  reimburse the contractor which comply with section 2152(b) of the act
				  (40
				  P. S. §
												991.2152(b))
				  which relates to operational standards for CREs compensation.
(2) The standards for the plan's oversight of
				  the contractor.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.676 - Enrollee rights

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall
				  have a written policy that shall state the plan's commitment to treating an
				  enrollee in a manner that respects the enrollee's rights and shall include the
				  plan's expectations of a member's responsibilities.
(b) An HMO shall offer to each enrollee, who
				  becomes ineligible to continue as a part of a group subscriber agreement, a
				  nongroup subscription agreement offering the same level of benefits as are
				  available to a group subscriber.
(c) An HMO may not expel or refuse to
				  reenroll an enrollee solely because of the enrollee's health care needs, nor
				  refuse to enroll individual subscribers of a group on the basis of health
				  status or health care needs of the individuals.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.677 - Requirements of definitions of "medical necessity"

Current through Register Vol. 54, No. 28, July 13, 2024
The definition of "medical necessity" shall be the same in
					 the plan's provider contracts, enrollee contracts and other materials used to
					 evaluate appropriateness and to determine coverage of health care services. The
					 definition shall comply with the HMO Act, the PPO Act, Act 68 and this
					 chapter.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.678 - PCPs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall
				  make available to each enrollee a PCP to supervise and coordinate the health
				  care of the enrollee.
(b) A PCP
				  shall meet the following minimum standards, unless a specialty health care
				  provider is approved by the plan to serve as a designated PCP as provided for
				  in §
										9.683 (relating to standing
				  referrals or specialists as pimary care providers):
(1) Provide office hours accessible to
				  enrollees of a minimum of 20 hours-per-week.
(2) Be available directly or through on-call
				  arrangements with other qualified plan participating PCPs, 24 hours-per-day, 7
				  days-per-week for urgent and emergency care and to provide triage and
				  appropriate treatment or referrals for treatment. A participating provider may
				  arrange for on-call services with a nonparticipating provider if the plan
				  approves the arrangement, agrees to provide the level-of-benefit for the
				  service provided by the nonparticipating provider, and agrees to hold the
				  enrollee harmless for any errors committed by the nonparticipating provider
				  that would result in noncoverage of covered benefits or would mislead the
				  enrollee into believing a noncovered service would be covered.
(3) Maintain medical records in accordance
				  with plan standards and accepted medical practice.
(4) Maintain hospital privileges or an
				  alternate arrangement for admitting an enrollee, approved by the plan, that
				  provides for timeliness of information and communication to facilitate the
				  admission, treatment, discharge and follow-up care necessary to ensure
				  continuity of services and care to the enrollee.
(5) Possess an unrestricted license to
				  practice in this Commonwealth.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.679 - Access requirements in service areas

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall only provide coverage to
				  enrollees who work or reside in a service area when the plan has been approved
				  to operate in that service area by the Department.
(b) A plan seeking to expand its service area
				  beyond that which was initially approved shall file with the Department a
				  service area expansion request.
(c)
				  A plan shall report to the Department any probable loss from the network of any
				  general acute care hospital and any primary care provider, whether an
				  individual practice or a group practice, with 2,000 or more assigned
				  enrollees.
(d) Except as otherwise
				  authorized in this section, a plan shall provide for at least 90% of its
				  enrollees in each county in its service area, access to covered services that
				  are within 20 miles or 30 minutes travel from an enrollee's residence or work
				  in a county designated as a metropolitan statistical area (MSA) by the Federal
				  Census Bureau, and within 45 miles or 60 minutes travel from an enrollee's
				  residence or work in any other county.
(e) A plan shall at all times assure enrollee
				  access to primary care providers, speciality care providers and other health
				  care facilities and services necessary to provide covered benefits. At a
				  minimum, the following health care services must be available in accordance
				  with the standards in subsection (d):
(1)
				  General acute inpatient hospital services.
(2) Common laboratory and diagnostic
				  services.
(3) Primary
				  care.
(4) General
				  surgery.
(5) Orthopedic
				  surgery.
(6) Obstetrical and
				  gynecological services.
(7)
				  Ophthalmology.
(8) Allergy and
				  immunology.
(9)
				  Anesthesiology.
(10)
				  Otolaryngology.
(11) Physical
				  medicine and rehabilitation.
(12)
				  Psychiatry and neurology.
(13)
				  Neurological surgery.
(14)
				  Urology.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.680 - Access for persons with disabilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall file with the Department its
				  policies, plans and procedures for ensuring that it has within its provider
				  network participating health care providers that are physically accessible to
				  people with disabilities, in accordance with Title III of the Americans with
				  Disabilities Act of 1990 (42
				  U.S.C.A. §§
											12181-12188.)
(b) A plan shall file with the Department its
				  policies, plans and procedures for ensuring that it has within its provider
				  network participating health care providers who can communicate with
				  individuals with sensory disabilities, in accordance with Title III of the
				  Americans with Disabilities Act of 1990.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.681 - Health care providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall
				  provide to enrollees a list by specialty of the name, address and telephone
				  number of participating health care providers to which an enrollee may have
				  access either directly or through a referral. The list may be a separate
				  document, which may be a regional or county directory, and shall be updated at
				  least annually. The plan shall satisfy the following in providing the list:
(1) If it provides a regional or county
				  directory, the plan shall make enrollees aware that other regional directories
				  or a full directory are available upon request.
(2) If it provides a list of participating
				  providers for only a specific type of provider or service, the plan shall
				  include in the list all participating providers authorized to provide those
				  services. Information shall be provided as required under 31 Pa. Code §
											154.16 (relating to information
				  for enrollees).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.682 - Direct access for obstetrical and gynecological care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall permit enrollees direct
				  access to obstetrical and gynecological services for maternity and
				  gynecological care, including medically necessary and appropriate follow-up
				  care and referrals, for diagnostic testing related to maternity and
				  gynecological care from participating health care providers without prior
				  approval from a primary care provider. Time restrictions may not apply to the
				  direct accessing of these services by enrollees.
(b) A plan may require a provider of
				  obstetrical or gynecological services to obtain prior authorization for
				  selected services, such as diagnostic testing for subspecialty care-for
				  example, reproductive endocrinology, oncologic gynecology, and maternal and
				  fetal medicine.
(c) A plan shall
				  develop policies and procedures that describe the terms and conditions under
				  which a directly accessed health care provider may provide and refer for health
				  care services with and without obtaining prior plan approval. The plan shall
				  have these policies and procedures approved by its quality assurance committee.
				  The plan shall provide these terms and conditions to all health care providers
				  who may be directly accessed for maternity and gynecological care.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.683 - Standing referrals or specialists as primary care providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall
				  adopt and maintain procedures whereby an enrollee with a life-threatening,
				  degenerative or disabling disease or condition shall, upon request, receive an
				  evaluation by the plan and, if the plan's established standards are met, the
				  procedures shall allow for the enrollee to receive either a standing referral
				  to a specialist with clinical expertise in treating the disease or condition,
				  or the designation of a specialist to assume responsibility to provide and
				  coordinate the enrollee's primary and specialty care.
(b) The plan's procedures shall:
(1) Ensure the plan has established
				  standards, including policies, procedures and clinical criteria for conducting
				  the evaluation and issuing or denying the request, including a process for
				  reviewing the clinical expertise of the requested specialist. The plan shall
				  have its standards approved by its quality improvement or quality assurance
				  committee.
(2) Provide for
				  evaluation by appropriately trained and qualified personnel.
(3) Include a treatment plan approved by the
				  plan in consultation with the primary care provider, the enrollee and as
				  appropriate, the specialist, and provided in writing to the specialist who will
				  be serving as the primary care provider or receiving the standing
				  referral.
(4) Be subject to the
				  plan's utilization management requirements and other established utilization
				  management and quality assurance criteria.
(5) Ensure that a standing referral to, or
				  the designation of a specialist as, a primary care provider will be made to
				  participating health care providers when possible.
(6) Ensure the plan issues a written decision
				  regarding the request for a standing referral or designation of a specialist as
				  a primary care provider within a reasonable period of time taking into account
				  the nature of the enrollee's condition, but within 45 days after the plan's
				  receipt of the request.
(7) Ensure
				  the written decision denying the request provides information about the right
				  to appeal the decision through the grievance process.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.684 - Continuity of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Provider
				  terminations initiated by the plan shall be governed as follows:
(1) Except as noted in subsections (i) and
				  (j), an enrollee may continue an ongoing course of treatment, at the option of
				  the enrollee, for up to 60 days from the date the enrollee is notified by the
				  plan of the termination or pending termination of a participating health care
				  provider.
(2) If the provider who
				  is terminated is a primary care provider, the plan shall provide written notice
				  of the termination to each enrollee assigned to that primary care provider and
				  shall request and facilitate the enrollee's transfer to another primary care
				  provider.
(3) If the provider who
				  is terminated is not a primary care provider, the plan shall notify all
				  affected enrollees identified through referral and claims data.
(4) Written notice from the plan shall
				  include instructions as to how to exercise the continuity of care option,
				  including qualifying criteria, the procedure for notifying the plan of the
				  enrollee's intention and how the enrollee will be notified that a continuing
				  care arrangement has been agreed to by the provider and the plan.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter H - AVAILABILITY AND ACCESS › Section 9.685 - Standards for approval of point-of-service products

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a plan offers a point-of-service
				  product, it shall submit a formal product filing for the POS product to the
				  Department and the Insurance Department.
(b) A plan may offer POS options to groups
				  and enrollees, if the plan:
(1) Has a system
				  for tracking, monitoring and reporting enrollee self-referrals for the
				  following purposes:
(i) To ensure that
				  self-referral activity is not occurring because of an access problem, a
				  deliberate attempt to force an enrollee to bypass a primary care provider for
				  nonmedical reasons or over restrictive or burdensome plan
				  requirements.
(ii) To promptly
				  investigate any PCP practice in which enrollees are utilizing substantially
				  higher levels of non-PCP referred care than average, to ensure that enrollee
				  self-referrals are not a reflection of access or quality problems on the part
				  of the PCP practice, inappropriate patient direction or burdensome plan
				  requirements.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.702 - Complaints and grievances

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General
(1) A plan shall
				  have a two-level complaint procedure and a two-level grievance procedure which
				  meets the requirements of sections 2141, 2142, 2161 and 2162 of the act
				  (40
				  P. S. §§
												991.2141,
				  991.2142,
				  991.2161 and
				  991.2162) and this
				  subchapter.
(2) The plan may not
				  incorporate administrative requirements, time frames or tactics to directly or
				  indirectly discourage the enrollee or health care provider from, or
				  disadvantage the enrollee or health care provider in utilizing the procedures.
				  The following apply if the enrollee or health care provider believes the plan
				  is violating this paragraph:
(i) An enrollee
				  or a health care provider may contact the Department to complain that a plan's
				  administrative procedures or time frames are being applied to discourage or
				  disadvantage the enrollee or health care provider in utilizing the
				  procedures.
(ii) The Department
				  will investigate the allegations, and take action it deems necessary and
				  appropriate under Act 68.
(iii)
				  Referral of the allegations to the Department will not operate to delay the
				  processing of the complaint or grievance review.
(3) At any time during the complaint or
				  grievance process, an enrollee may choose to designate a representative to
				  participate in the complaint or grievance process on the enrollee's behalf. The
				  enrollee or the enrollee's representative shall notify the plan of the
				  designation.
(4) The plan shall
				  make a plan employee available to assist the enrollee or the enrollee's
				  representative at no charge in preparing the complaint or grievance if a
				  request for assistance is made by the enrollee or the representative at any
				  time during the complaint or grievance process. The plan employee made
				  available by the plan may not have participated in any plan decision with
				  regard to the complaint or grievance.
(5) As part of its complaint and grievance
				  process, a plan shall have a toll-free telephone number for an enrollee to use
				  to obtain information regarding the filing and status of a complaint or
				  grievance. The plan shall make reasonable accomodations to enable enrollees
				  with disabilities and non-English speaking enrollees to secure the
				  information.
(6) A plan shall
				  provide copies of its complaint and grievance procedures to the Department for
				  review and approval under §
											9.710 (relating to approval of
				  plan enrollee complaint and enrollee and provider grievance systems). The
				  Department will use the procedures as a reference when assisting enrollees who
				  contact the Department directly.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.703 - Internal complaint process

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  plan shall establish, operate and maintain an internal complaint process which
				  meets the requirements of section 2141 of the act (40 P. S. §
											991.2141), and this subchapter. The process
				  shall address how an enrollee or the enrollee's representative may file
				  complaints by which the enrollee or the enrollee's representative seek to have
				  the plan review and change plan decisions regarding participating health care
				  providers, or the health plan coverage, plan operations and management policies
				  of the plan.
(b) A plan shall
				  permit an enrollee or the enrollee's representative to file with it a written
				  or oral complaint.
(c) A plan's
				  internal complaint process shall include the following standards:
(1)
First level review
.
(i) Upon receipt of the complaint, the plan
				  shall provide written confirmation of its receipt to the enrollee and the
				  enrollee's representative, if the enrollee has designated one, including the
				  following information:
(A) That the plan
				  considers the matter to be a complaint, and that the enrollee or the enrollee's
				  representative may question this classification by contacting the
				  Department.
(B) That the enrollee
				  may appoint a representative to act on the enrollee's behalf at any time during
				  the process.
(C) That the enrollee
				  or the enrollee's representative may review information related to the
				  complaint upon request and submit additional material to be considered by the
				  plan.
(D) That the enrollee or the
				  enrollee's representative may request the aid of a plan employee who has not
				  participated in previous decisions to deny coverage for the issue in dispute,
				  at no charge, in preparing the enrollee's complaint.
(E) If the plan chooses to permit attendance
				  at the first level review, that the enrollee and the enrollee's representative
				  may attend the first level review.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.704 - Appeal of a complaint decision

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  An enrollee shall have 15 days from receipt of the second level review decision
				  of a complaint to file an appeal of the decision with either the Department or
				  the Insurance Department. The appeal shall be in writing unless the enrollee
				  requests to file the appeal in an alternative format. The Department will make
				  staff available to transcribe an oral appeal.
(b) The appeal from the enrollee shall
				  include the following:
(1) The enrollee's
				  name, address and telephone number.
(2) Identification of the plan.
(3) The enrollee's plan identification
				  number.
(4) A brief description of
				  the issue being appealed.
(5) The
				  second level denial letter from the plan concerning the complaint.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.705 - Internal grievance process

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  plan shall establish, operate and maintain an internal enrollee grievance
				  process in compliance with sections 2161 and 2162 of the act (40 P. S.
				  §§
											991.2161 and
				  991.2162) and this
				  subchapter, for the purposes of reviewing a denial of coverage for a health
				  care service on the basis of medical necessity and appropriateness.
(b) The enrollee or the enrollee's
				  representative, or a health care provider with written consent of the enrollee,
				  may file a written grievance with the plan. The plan shall make staff available
				  to record an oral grievance for an enrollee who is unable by reason of
				  disability or language barrier to file a grievance in writing.
(c) The plan's internal grievance process
				  shall include the following standards:
(1)
First level review
.
(i) Upon
				  receipt of the grievance, the plan shall provide written confirmation of its
				  receipt to the enrollee and the enrollee's representative, if the enrollee has
				  designated one, and the health care provider if the health care provider filed
				  the grievance with enrollee consent, and shall also provide the following
				  information:
(A) That the plan considers the
				  matter to be a grievance, and that the enrollee, the enrollee's representative,
				  or health care provider may question this classification by contacting the
				  Department.
(B) That the enrollee
				  may appoint a representative to act on the enrollee's behalf at any time during
				  the internal grievance process.
(C)
				  That the enrollee, the enrollee's representative, or the health care provider
				  that filed the grievance with enrollee consent may review information related
				  to the grievance upon request and submit additional material to be considered
				  by the plan.
(D) That the enrollee
				  or the enrollee's representative may request the aid of a plan employee who has
				  not participated in previous decisions to deny coverage for the issue in
				  dispute, at no charge, in preparing the enrollee's first level
				  grievance.
(E) If the plan chooses
				  to permit attendance at the first level review, that the enrollee, the
				  enrollee's representative, and the health care provider who filed the
				  grievance, may attend the first level review.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.708 - External grievance reviews by CREs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The assigned CRE shall review and issue a
				  written decision within 60 days of the filing of the request for an external
				  grievance review. The decision shall be sent to the enrollee and the enrollee's
				  representative, the health care provider, if the health care provider filed the
				  grievance with enrollee consent, the plan, and the Department. The decision
				  shall include the credentials of the individual reviewer, a list of the
				  information considered in reaching the decision, the basis and clinical
				  rationale for the decision, a brief statement of the decision, and the
				  statement that the enrollee, and the enrollee's representative, or the health
				  care provider have 60 days from receipt of the decision to appeal to a court of
				  competent jurisdiction.
(b) The
				  assigned CRE shall review the second level grievance review decision based on
				  whether the health care service denied by the internal grievance process is
				  medically necessary and appropriate under the terms of the plan.
(c) The assigned CRE shall review all
				  information considered by the plan in reaching any prior decision to deny
				  coverage for the health care service in question, and information provided in
				  §
										9.707 (relating to external
				  grievance process).
(d) The
				  assigned CRE's decision shall be made by either of the following:
(1) One or more physicians certified by a
				  board approved by the American Board of Medical Specialties or the American
				  Board of Osteopathic Specialties, practicing within the same or similar
				  specialty that typically manages or recommends treatment for the health care
				  service being reviewed.
(2) One or
				  more licensed physicians or approved licensed psychologists in active clinical
				  practice in the same or similar specialty that typically manages or recommends
				  treatment for the health care service being reviewed.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.709 - Expedited review

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall
				  make an expedited review procedure available to enrollees if the enrollee's
				  life, health or ability to regain maximum function would be placed in jeopardy
				  by delay occasioned by the review process in this subchapter.
(b) An enrollee may request from the plan an
				  expedited review at any stage of the plan's review process if the enrollee's
				  life, health or ability to regain maximum function would be placed in jeopardy
				  by delay occasioned by the review process in this subchapter.
(c) In order to obtain an expedited review,
				  an enrollee shall provide the plan with a certification, in writing, from the
				  enrollee's physician that the enrollee's life, health or ability to regain
				  maximum function would be placed in jeopardy by delay occasioned by the review
				  process in this subchapter. The certification shall include a clinical
				  rationale and facts to support the physician's opinion. The plan shall accept
				  the physician's certification, and provide an expedited review.
(d) The plan's internal expedited review
				  process shall be bound by the same rules and procedures as the second level
				  grievance review process with the exception of the following:
(1) The time frames.
(2) The requirements of §
											9.705(c)(2)(iii)(b), (c) and
				  (i) (relating to internal grievance process).
				  If the plan cannot accommodate the enrollee as to time and distance, or have
				  the committee physically present at the review, the plan shall hold the hearing
				  telephonically and ensure that all information presented at the hearing is read
				  into the record.
(3) The
				  requirements of §
											9.705(c)(3)(iii)
				  with respect to providing the report 7 days prior to the review. The plan shall
				  provide a copy of the report to the enrollee prior to the hearing if possible.
				  If not, the plan may read the report into the record at the hearing, and shall
				  provide the enrollee with a copy of the report at that time.
(4) It is the responsibility of the enrollee
				  or the health care provider to provide information to the plan in an expedited
				  manner to allow the plan to conform to the requirements of this
				  section.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.710 - Approval of plan enrollee complaint and enrollee and provider grievance systems

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  will review the plan's enrollee complaint and grievance systems under its
				  authority to review the operations of the plan and its quality assurance
				  systems, and complaint and grievance resolution systems to ensure that they
				  meet the requirements of Act 68 and this chapter.
(b) If changes are made by the plan that have
				  the potential to impact the complaint or grievance process or the outcome of
				  cases, the plan shall submit a copy of the proposed changes to the Department
				  for prior review 60 days before the plan intends to implement the
				  changes.
(c) Complaint and
				  grievance procedures for special populations, such as Medicaid and Medicare HMO
				  enrollees, shall comply with Act 68 to the extent permitted by Federal law and
				  regulation.
The provisions of this §
												9.710 issued under Article XXI of
						The Insurance Company Law of 1921 (40 P. S. §§
													991.2101-991.2193); the HMO Act
						(40
						P. S. §§
													1551-1568); and section
						630 of the PPO Act (40 P. S. §
													764a).
This section cited in 28 Pa. Code §
												9.702 (relating to complaints and
						grievances).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.711 - Informal dispute resolution systems and alternative dispute resolution systems

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Informal dispute resolution systems
.
(1) A plan and a health care provider may
				  agree to an informal dispute resolution system for the review and resolution of
				  disputes between the health care provider and the plan. These disputes include
				  denials based on procedural errors and administrative denials involving the
				  level or types of health care service provided.
(2) Procedural errors and administrative
				  denials in which the enrollee is held financially harmless by virtue of the
				  provider contract or when the enrollee has never been advised by the plan in
				  writing that continued health care services would not be covered benefits, will
				  not be automatically viewed as grievances for the purposes of this subchapter
				  and may be addressed by informal dispute resolution systems.
(3) The informal dispute resolution system
				  agreed upon by the plan and its providers shall be included in the health care
				  provider contract with the plan, and shall be enforceable.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter J - HEALTH CARE PROVIDER CONTRACTS › Section 9.721 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
This subchapter shall apply to provider contracts between
					 plans subject to Act 68 and health care providers; plans and IDSs; and IDSs and
					 health care providers.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter J - HEALTH CARE PROVIDER CONTRACTS › Section 9.722 - Plan and health care provider contracts

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A plan shall submit the standard form of
				  each type of health care provider contract, including any document incorporated
				  by reference into that contract, to the Department for review and approval. The
				  plan shall be responsible for assuring that the provider contract meets the
				  requirements of all applicable laws. The Department will review a provider
				  contract within 45 days of receipt of the contract. If the Department does not
				  approve or disapprove the contract within 45 days of receipt, the plan may use
				  the contract and it shall be presumed to meet the requirements of all
				  applicable laws. If, at any time, the Department finds that a contract is in
				  violation of law, the plan shall correct the violation.
(b) The plan shall submit any material change
				  or amendment to a standard health care provider contract, including a material
				  change or amendment to any document incorporated by reference into the
				  contract, to the Department 10 days before implementation of the change or
				  amendment except for changes required by law or regulation.
(c) To be approved by the Department, a
				  standard health care provider contract may not contain provisions permitting
				  the plan to sanction, terminate or fail to renew a health care provider's
				  participation for any of the following reasons:
(1) Advocating for medically necessary and
				  appropriate health care services for an enrollee.
(2) Filing a grievance on behalf of and with
				  the written consent of an enrollee, or helping an enrollee to file a
				  grievance.
(3) Protesting a plan
				  decision, policy or practice the health care provider believes interferes with
				  its ability to provide medically necessary and appropriate health
				  care.
(4) Taking another action
				  specifically permitted by sections 2113, 2121 and 2171 of the act
				  (40
				  P. S. §§
												991.2113,
				  991.2121 and
				  991.2171).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter J - HEALTH CARE PROVIDER CONTRACTS › Section 9.723 - IDS

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Standard IDS
				  contracts between the IDS and the plan and between the IDS and the health care
				  provider shall meet the standards of health care provider contracts in §
										9.722 (relating to plan and health
				  care provider contracts).
(b) A
				  plan and an IDS entering into an arrangement under this subchapter shall notify
				  the Department in writing in advance of any action which could result in the
				  IDS's participating providers being unavailable to provide covered services to
				  enrollees.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter J - HEALTH CARE PROVIDER CONTRACTS › Section 9.725 - IDS-provider contracts

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the IDS contract, the health care provider
					 contracts between the IDS and its participating health care providers shall be
					 submitted by the plan for review and approval to the Department. For this
					 purpose, the IDS shall provide the plan with a copy of these contracts. To
					 secure Department approval of a contract between the plan and the IDS, an
					 IDS-health care provider contract shall meet the following standards:
(1) The health care provider shall
				  acknowledge and agree that nothing contained in the IDS-provider contract
				  limits the following:
(i) The authority of the
				  plan to ensure the health care provider's participation in and compliance with
				  the plan's quality assurance, utilization management, enrollee complaint and
				  grievance systems and procedures or limits.
(ii) The Department's authority to monitor
				  the effectiveness of the plan's system and procedures or the extent to which
				  the plan adequately monitors any function delegated to the IDS, or to require
				  the plan to take prompt corrective action regarding quality of care or consumer
				  grievances and complaints.
(iii)
				  The plan's authority to sanction or terminate a health care provider found to
				  be providing inadequate or poor quality care or failing to comply with plan
				  systems, standards or procedures as agreed to by the IDS.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter K - CREs › CERTIFICATION › Section 9.741 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Sections
					 9.742-9.748 of this subchapter set
					 standards for the certification of CREs and the maintenance of that
					 certification.
(b) Sections
					 9.751-9.753 set operational standards
					 for entities performing UR.