Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter I - COMPLAINTS AND GRIEVANCES › Section 9.706 - Health care provider initiated grievances

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A health care provider may, with the
				  written consent of an enrollee that meets the requirements of subsection (g),
				  file a written grievance with a plan.
(b) A health care provider may obtain written
				  consent from an enrollee or the enrollee's legal representative to pursue a
				  grievance in lieu of the enrollee at the time of treatment. A health care
				  provider may not require an enrollee or the enrollee's legal representative to
				  sign a document authorizing the health care provider to file a grievance as a
				  condition of providing a health care service.
(c) Once a health care provider assumes
				  responsibility for filing a grievance, the health care provider may not bill
				  the enrollee or the enrollee's legal representative for services provided that
				  are the subject of the grievance until the external grievance review has been
				  completed or the enrollee or the enrollee's legal representative rescinds
				  consent for the health care provider to pursue the grievance. If the health
				  care provider chooses never to bill the enrollee or the enrollee's legal
				  representative for the services provided that are the subject of the grievance,
				  the health care provider may drop the grievance with notice to the enrollee and
				  the enrollee's legal representative in accordance with subsection
				  (g).
(d) If the health care
				  provider elects to appeal an adverse decision of a CRE, the health care
				  provider may not bill the enrollee or the enrollee's legal representative for
				  services provided that are the subject of the grievance until the health care
				  provider chooses not to appeal an adverse decision to a court of competent
				  jurisdiction.
(e) The consent of an
				  enrollee or the enrollee's legal representative to a health care provider to
				  pursue a grievance shall be in writing, shall be automatically rescinded upon
				  the failure of the health care provider to file or pursue a grievance under
				  this subchapter and shall include each of the following elements:
(1) The name and address of the enrollee and
				  of the policy holder, if they are different, the enrollee's date of birth and
				  the enrollee's identification number.
(2) If the enrollee is a minor, or is legally
				  incompetent, the name, address and relationship to the enrollee of the person
				  who signs the consent for the enrollee.
(3) The name, address and plan identification
				  number of the health care provider to whom the enrollee is providing the
				  consent.
(4) The name and address
				  of the plan to which the grievance will be submitted.
(5) An explanation of the specific service
				  for which coverage was provided or denied to the enrollee to which this consent
				  will apply.
(6) The following
				  statements:
(i) The enrollee or the enrollee's
				  representative may not submit a grievance concerning the services listed in
				  this consent form unless the enrollee or the enrollee's legal representative
				  rescinds consent in writing. The enrollee or the enrollee's legal
				  representative has the right to rescind a consent at any time during the
				  grievance process.
(ii) The consent
				  of the enrollee or the enrollee's legal representative shall be automatically
				  rescinded if the provider fails to file a grievance, or fails to continue to
				  prosecute the grievance through the second level review process.
(iii) The enrollee or the enrollee's legal
				  representative, if the enrollee is a minor or is legally incompetent, has read,
				  or has been read this consent form, and has had it explained to his
				  satisfaction. The enrollee or the enrollee's legal representative understands
				  the information in the enrollee's consent form.
(7) The dated signature of the enrollee, or
				  the enrollee's legal representative, and the dated signature of a
				  witness.