Current through Register Vol. 54, No. 44, November 2, 2024
(a) A plan shall
adopt and maintain procedures whereby an enrollee with a life-threatening,
degenerative or disabling disease or condition shall, upon request, receive an
evaluation by the plan and, if the plan's established standards are met, the
procedures shall allow for the enrollee to receive either a standing referral
to a specialist with clinical expertise in treating the disease or condition,
or the designation of a specialist to assume responsibility to provide and
coordinate the enrollee's primary and specialty care.
(b) The plan's procedures shall:
(1) Ensure the plan has established
standards, including policies, procedures and clinical criteria for conducting
the evaluation and issuing or denying the request, including a process for
reviewing the clinical expertise of the requested specialist. The plan shall
have its standards approved by its quality improvement or quality assurance
committee.
(2) Provide for
evaluation by appropriately trained and qualified personnel.
(3) Include a treatment plan approved by the
plan in consultation with the primary care provider, the enrollee and as
appropriate, the specialist, and provided in writing to the specialist who will
be serving as the primary care provider or receiving the standing
referral.
(4) Be subject to the
plan's utilization management requirements and other established utilization
management and quality assurance criteria.
(5) Ensure that a standing referral to, or
the designation of a specialist as, a primary care provider will be made to
participating health care providers when possible.
(6) Ensure the plan issues a written decision
regarding the request for a standing referral or designation of a specialist as
a primary care provider within a reasonable period of time taking into account
the nature of the enrollee's condition, but within 45 days after the plan's
receipt of the request.
(7) Ensure
the written decision denying the request provides information about the right
to appeal the decision through the grievance process.
(c) A plan shall have mechanisms in place to
review the effect of this procedure, and shall present the results to its
quality improvement or quality assurance committee on an annual
basis.
This section cited in 28 Pa. Code §
9.678 (relating to
PCPs).
