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

Universal Citation: 28 PA Code ยง 9.681

Current through Register Vol. 54, No. 44, November 2, 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).

(b) A plan shall include a clear disclaimer in the provider directories it provides to enrollees that the plan cannot guarantee continued access during the term of the enrollee's enrollment to a particular health care provider, and that if a participating health care provider used by the enrollee ceases participation, the plan will provide access to other providers with equivalent training and experience.

(c) A plan that has no participating health care providers within the approved service area available to provide covered health care services shall arrange for and provide coverage for services provided by a nonparticipating health care provider. The plan shall cover the nonnetwork services at the same level of benefit as if a network provider had been available.

(d) A plan shall have written procedures governing and ensuring the availability and accessibility of frequently utilized health care services, including the following:

(1) Well-patient examinations and immunizations.

(2) Emergency telephone consultation on a 24-hour-per-day, 7 day-per-week basis.

(3) Treatment of acute emergencies.

(4) Treatment of acute minor illnesses.

(5) Routine appointments.

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