Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part I - General Health
Chapter 9 - MANAGED CARE ORGANIZATIONS
Subchapter K - CREs
CERTIFICATION
Section 9.744 - CREs participating in internal and external grievance reviews
Universal Citation: 28 PA Code ยง 9.744
Current through Register Vol. 54, No. 44, November 2, 2024
(a) To be certified to review internal and external grievances, the applicant shall supply the following additional information to the Department for review, along with the application:
(1) The name and type of
business of each corporation, affiliate or other organization that the
applicant controls; the nature and extent of the affiliation or control; and a
chart or list clearly identifying the relationship between the applicant and
affiliates.
(2) The name, title,
address and telephone number of a primary and at least one backup designee with
whom the Department may communicate regarding assignment of external grievances
and other issues.
(3) A disclosure
of any known potential conflict of interest which would preclude its review of
an external grievance-for example, ownership of or affiliation with a competing
plan or other health insurance company.
(4) A description of the applicant's:
(i) Capacity and procedures for notifying the
health care provider of additional facts or documents required to complete the
UR within 48 hours of receipt of the request for an expedited review.
(ii) Systems and procedures, including
staffing and resources, to meet the time frames for decisions as specified in
section 2152 of the act (40 P. S. §
991.2152). 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 for
internal and external grievance reviews. To be certified, an applicant shall
demonstrate it has a contracted and credentialed network of providers, which
shall include, at a minimum, all general specialities represented by the
American Board Of Medical Specialities (ABMS), the subspecialties of oncology
and physician reviewers specializing in transplanation. An applicant shall also
provide a description of its ability to obtain within 24 hours the services of
a qualified peer reviewer from any speciality or subspecialty required for an
external grievance review.
(iii)
Capability and agreement to receive and decide all external grievances, or just
behavioral health grievances if so desired, and the process for ensuring that
clinical peer reviewers, when making an external appeal determination
concerning medical necessity, consider the clinical standards of the plan, the
information provided concerning the enrollee, the attending physician's
recommendation and applicable generally accepted practice guidelines developed
by the Federal government, National or professional medical societies, boards
and associations.
(iv) The
capacity, procedures and agreement to maintain the information obtained in the
review of the grievances, including outcomes, for at least 3 years in a manner
that is confidential and unavailable to any affiliated entity or person who may
be a direct or indirect competitor to the plan being reviewed.
(v) Fee schedule for the conduct of grievance
reviews. An applicant will not be certified as a CRE unless the proposed fees
for external reviews are determined to be reasonable by the
Department.
(5) A
certification that the following conditions apply:
(i) The CRE is willing and able to
participate on a rotational basis in grievance reviews.
(ii) Internal and external grievances and
expedited grievances will be reviewed and processed in accordance with Act 68
and Subchapter I (relating to complaints and grievances).
(b) The Department will add the name of each CRE to its rotational list of CREs certified to conduct external grievances.
This section cited in 28 Pa. Code § 9.741 (relating to applicability).
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