Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter K - CREs › CERTIFICATION › Section 9.743 - Content of an application for certification as a CRE

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A CRE seeking certification shall submit
					 two copies of the Department's application to the Department's Bureau of
					 Managed Care.
(b) The application
					 shall contain the following:
(1) The name,
					 address and telephone number of the applicant as it should appear on the
					 Department's official list of certified CREs.
(2) Information relating to its organization,
					 structure and function, including the following:
(i) The location of the principal office
					 handling UR.
(ii) The articles of
					 incorporation and bylaws, or similar documents regulating the internal affairs
					 of the applicant.
(iii) The name of
					 each owner of more than 5% of the shares of the corporation, if the applicant
					 is a public corporation.
(iv) A
					 chart showing the internal organization of the applicant's management and
					 administrative staff.
(3)
					 The names and resumes of each officer, director and senior
					 management.
(4) A listing of each
					 plan in this Commonwealth for which the applicant currently conducts
					 UR.
(5) A description of the
					 applicant's:
(i) Ability to respond to each
					 telephone call received as required by section 2152 of the act (40 P. S. §
														991.2152), including toll-free telephone
					 numbers and the applicant's system to provide access during nonbusiness
					 hours.
(ii) Acceptable selection
					 and credentialing procedures and criteria for physician and psychologist
					 clinical peer reviewers.
(iii)
					 Ability to arrange for a wide range of health care providers to conduct
					 reviews. 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.
(iv)
					 Procedures for protecting the confidentiality of medical records and
					 certification that the applicant will comply with the confidentiality
					 provisions in section 2131 of the act (40 P. S. §
														991.2131) and other applicable State and
					 Federal laws and regulations imposing confidentiality requirements.
(v) Procedures to ensure that a health care
					 provider is able to verify that an individual requesting information on behalf
					 of the plan is a representative of the plan.
(vi) Capacity to maintain a written record of
					 UR decisions adverse to enrollees for at least 3 years, including a detailed
					 justification and all required notifications to the health care provider and
					 enrollee.
(vii) Evidence of
					 approval, certification or accreditation received by a Nationally recognized
					 accrediting body in the area of UR, if it has secured the approval,
					 certification or accreditation.
(viii) The length of time the applicant has
					 been operating in this Commonwealth, if applicable.
(ix) A list of three clients, if any, for
					 which the applicant has conducted UR including the name, address, position and
					 telephone number of a contact person for each client. The Department may
					 contact these references for an assessment of the applicant's past performance
					 and its ability to meet the time frames for prospective, concurrent and
					 retrospective UR in section 2152 of the act (40 P. S. §
														991.2152).