Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PEER REVIEW › Section 69.52 - Peer review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 provider's bill shall be referred to a PRO only when circumstances or
					 conditions relating to medical and rehabilitative services provided cause a
					 prudent person, familiar with PRO procedures, standards and practices, to
					 believe it necessary that a PRO determine the reasonableness and necessity of
					 care, the appropriateness of the setting where the care is rendered, and the
					 appropriateness of the delivery of the care. An insurer shall notify a
					 provider, in writing, when referring bills for PRO review at the time of the
					 referral.
(b) An insurer shall make
					 a referral to a PRO within 90 days of the insurer's receipt of sufficient
					 documentation supporting the bill. An insurer shall pay bills for care that are
					 not referred to a PRO within 30 days after the insurer receives sufficient
					 documentation supporting the bill. If an insurer makes its referral after the
					 30th day and on or before the 90th day, the provider's bill for care shall be
					 paid.
(c) During an initial
					 determination, a PRO shall request in writing from the provider the records and
					 documents necessary to undertake its review. The PRO shall afford the provider
					 an opportunity to discuss the case with the reviewer and to submit information
					 to the reviewer prior to a final determination.
(d) A PRO's initial determination shall be
					 completed within 30 days after the receipt of requested information. When a
					 provider fails to respond to the PRO's inquiry or provide requested
					 information, a PRO may commence its review 30 days after the request for
					 information is postmarked. If additional information critical for the outcome
					 of the determination is submitted by a provider or requested by a PRO, the
					 30-day review period may be tolled up to 20 days for the information to be
					 received and taken into consideration.
(e) A PRO shall provide a written analysis,
					 including specific reasons for its decision, to insurers, which shall within 5
					 days of receipt, provide copies to providers and insureds. Without the written
					 analysis, the review may not be considered an initial determination and unpaid
					 provider bills subject to the review shall be paid by the insurer. An insurer
					 may request another initial determination if the request is made within 90 days
					 of its receipt of the bill and supporting documentation in accordance with
					 subsection (b). The written analysis of the initial determination shall notify
					 all parties that they have 30 days from the day the initial determination is
					 effected to request a reconsideration and the process and location for filing a
					 request for reconsideration.
(f) A
					 PRO's initial determination resulting in the denial of a provider's claim, in
					 whole or in part, shall be effected by a licensed practitioner of like
					 speciality or a licensed practitioner with experience providing and prescribing
					 the care subject to the review.
(g)
					 Absent a change of condition, a decision of not medically necessary by the PRO
					 is basis for an insurer to deny payment for similar services to the same
					 insured resulting from the same accident. The insured or subsequent provider
					 has the right to request a reconsideration of the initial determination for
					 subsequent treatment or services received or provided.
(h) An insurer, provider or insured may
					 request, in writing, reconsideration of the initial PRO determination within 30
					 days from the date the initial determination is effected. A PRO may set a
					 reasonable charge for a reconsideration but the charge for a reconsideration
					 may not exceed the charge for the initial review. An insurer shall make full
					 payment of the charge for reconsideration to the PRO, but the amount paid for
					 the reconsideration shall be ultimately borne by the party against whom a
					 reconsideration determination is made.
(i) A reconsideration shall be effected by a
					 licensed practitioner of like speciality as the provider subject to the
					 reconsideration review. The licensed practitioner effecting the reconsideration
					 review may not be the same licensed practitioner who rendered the PRO's initial
					 determination.
(j) A PRO shall
					 afford the party requesting reconsideration an opportunity to discuss the case
					 with the reviewer and to submit additional information identified by the
					 reviewer before making a final determination of the reconsideration.
(k) A reconsideration shall be based upon the
					 information that led to the initial determination, new information found in
					 medical records or additional evidence submitted by the requesting
					 party.
(l) A PRO shall complete a
					 reconsideration within 30 days after receipt of the information submitted under
					 subsection (k). If additional information critical for the outcome of the
					 determination is submitted by a provider or requested by a PRO, the 30-day
					 review period may be tolled up to 20 days for the information to be received
					 and taken into consideration. A PRO shall send written notification of the
					 reconsideration determination to the insurer, which shall within 5 days of
					 receipt provide copies to providers and insureds. The written notice shall
					 contain the basis and rationale for the reconsideration
					 determination.
(m) Upon
					 determination of a reconsideration by a PRO, an insurer, provider or insured
					 may appeal the determination to the courts.
(n) The insured may not be billed during the
					 peer review process.
This section cited in 31 Pa. Code §
													69.54 (relating to PRO reporting
						  responsibility); and 31 Pa. Code §
													69.55 (relating to criteria for
						  Department approval of a PRO).