Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter K - CREs › CERTIFICATION › Section 9.744 - CREs participating in internal and external grievance reviews

Current through Register Vol. 54, No. 28, July 13, 2024
(a) To be certified
					 to review internal and external grievances, the applicant shall supply the
					 following additional information to the Department for review, along with the
					 application:
(1) The name and type of
					 business of each corporation, affiliate or other organization that the
					 applicant controls; the nature and extent of the affiliation or control; and a
					 chart or list clearly identifying the relationship between the applicant and
					 affiliates.
(2) The name, title,
					 address and telephone number of a primary and at least one backup designee with
					 whom the Department may communicate regarding assignment of external grievances
					 and other issues.
(3) A disclosure
					 of any known potential conflict of interest which would preclude its review of
					 an external grievance-for example, ownership of or affiliation with a competing
					 plan or other health insurance company.
(4) A description of the applicant's:
(i) Capacity and procedures for notifying the
					 health care provider of additional facts or documents required to complete the
					 UR within 48 hours of receipt of the request for an expedited review.
(ii) Systems and procedures, including
					 staffing and resources, to meet the time frames for decisions as specified in
					 section 2152 of the act (40 P. S. §
														991.2152). The applicant shall have access to
					 a pool of clinical peer reviewers sufficient to reasonably assure that
					 appropriately qualified reviewers will be available on a timely basis for
					 internal and external grievance reviews. To be certified, an applicant shall
					 demonstrate it has a contracted and credentialed network of providers, which
					 shall include, at a minimum, all general specialities represented by the
					 American Board Of Medical Specialities (ABMS), the subspecialties of oncology
					 and physician reviewers specializing in transplanation. An applicant shall also
					 provide a description of its ability to obtain within 24 hours the services of
					 a qualified peer reviewer from any speciality or subspecialty required for an
					 external grievance review.
(iii)
					 Capability and agreement to receive and decide all external grievances, or just
					 behavioral health grievances if so desired, and the process for ensuring that
					 clinical peer reviewers, when making an external appeal determination
					 concerning medical necessity, consider the clinical standards of the plan, the
					 information provided concerning the enrollee, the attending physician's
					 recommendation and applicable generally accepted practice guidelines developed
					 by the Federal government, National or professional medical societies, boards
					 and associations.
(iv) The
					 capacity, procedures and agreement to maintain the information obtained in the
					 review of the grievances, including outcomes, for at least 3 years in a manner
					 that is confidential and unavailable to any affiliated entity or person who may
					 be a direct or indirect competitor to the plan being reviewed.
(v) Fee schedule for the conduct of grievance
					 reviews. An applicant will not be certified as a CRE unless the proposed fees
					 for external reviews are determined to be reasonable by the
					 Department.
(5) A
					 certification that the following conditions apply:
(i) The CRE is willing and able to
					 participate on a rotational basis in grievance reviews.
(ii) Internal and external grievances and
					 expedited grievances will be reviewed and processed in accordance with Act 68
					 and Subchapter I (relating to complaints and grievances).