Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part I - General Health
Chapter 9 - MANAGED CARE ORGANIZATIONS
Subchapter I - COMPLAINTS AND GRIEVANCES
Section 9.709 - Expedited review

Universal Citation: 28 PA Code ยง 9.709

Current through Register Vol. 54, No. 44, November 2, 2024

(a) A plan shall make an expedited review procedure available to enrollees if the enrollee's life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the review process in this subchapter.

(b) An enrollee may request from the plan an expedited review at any stage of the plan's review process if the enrollee's life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the review process in this subchapter.

(c) In order to obtain an expedited review, an enrollee shall provide the plan with a certification, in writing, from the enrollee's physician that the enrollee's life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the review process in this subchapter. The certification shall include a clinical rationale and facts to support the physician's opinion. The plan shall accept the physician's certification, and provide an expedited review.

(d) The plan's internal expedited review process shall be bound by the same rules and procedures as the second level grievance review process with the exception of the following:

(1) The time frames.

(2) The requirements of § 9.705(c)(2)(iii)(b), (c) and (i) (relating to internal grievance process). If the plan cannot accommodate the enrollee as to time and distance, or have the committee physically present at the review, the plan shall hold the hearing telephonically and ensure that all information presented at the hearing is read into the record.

(3) The requirements of § 9.705(c)(3)(iii) with respect to providing the report 7 days prior to the review. The plan shall provide a copy of the report to the enrollee prior to the hearing if possible. If not, the plan may read the report into the record at the hearing, and shall provide the enrollee with a copy of the report at that time.

(4) It is the responsibility of the enrollee or the health care provider to provide information to the plan in an expedited manner to allow the plan to conform to the requirements of this section.

(e) A plan shall conduct an expedited internal review and issue its decision within 48 hours of receipt of the enrollee's request for an expedited review accompanied by a physician's statement in accordance with subsection (c).

(f) The notification to the enrollee shall state the basis for the decision, including any clinical rationale, and the procedure for obtaining an expedited external review.

(g) The enrollee has 2 business days from the receipt of the expedited internal review decision to contact the plan to request an expedited external review.

(h) Within 24 hours of receipt of the enrollee request for an expedited external review, the plan shall submit a request for an expedited external review to the Department by Fax transmission or telephone call. The Department will make information available to the plan to enable the plan to have direct access to a CRE on weekends and State holidays.

(i) The Department will assign a CRE within 1 business day of receiving the request for an expedited review.

(j) When assigning a CRE, the Department will rely on information provided by the CRE as to any affiliations or contractual relationships with plans so as to avoid conflicts of interest.

(k) In all cases, the plan shall transfer a copy of the case file to the CRE for receipt on the next business day and the CRE shall have 2 business days to issue a decision.

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