Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part I - General Health
Chapter 9 - MANAGED CARE ORGANIZATIONS
Subchapter I - COMPLAINTS AND GRIEVANCES
Section 9.711 - Informal dispute resolution systems and alternative dispute resolution systems
Universal Citation: 28 PA Code ยง 9.711
Current through Register Vol. 54, No. 44, November 2, 2024
(a) Informal dispute resolution systems.
(1) A plan and a health care provider may
agree to an informal dispute resolution system for the review and resolution of
disputes between the health care provider and the plan. These disputes include
denials based on procedural errors and administrative denials involving the
level or types of health care service provided.
(2) Procedural errors and administrative
denials in which the enrollee is held financially harmless by virtue of the
provider contract or when the enrollee has never been advised by the plan in
writing that continued health care services would not be covered benefits, will
not be automatically viewed as grievances for the purposes of this subchapter
and may be addressed by informal dispute resolution systems.
(3) The informal dispute resolution system
agreed upon by the plan and its providers shall be included in the health care
provider contract with the plan, and shall be enforceable.
(b) Alternative dispute resolution systems.
(1) To be acceptable to the
Department, an alternative dispute resolution system shall:
(i) Be impartial.
(ii) Include specific and reasonable time
frames in which to initiate appeals, receive written information, conduct
hearings and render decisions.
(iii) Provide for final review and
determination.
(2) An
alternative dispute resolution system agreed upon by a plan and its
participating providers shall be included in the health care provider contracts
and shall be final and binding on both the plan and the health care
provider.
(3) An alternative
dispute resolution system may not be used for any extenal grievance filed by an
enrollee.
The provisions of this §9.711 issued under Article XXI of The Insurance Company Law of 1921 (40 P. S. §§ 991.2101-991.2193); the HMO Act (40 P. S. §§ 1551-1568); and section 630 of the PPO Act (40 P. S. § 764a).
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