Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part I - General Health
Chapter 9 - MANAGED CARE ORGANIZATIONS
Subchapter K - CREs
OPERATIONAL STANDARDS
Section 9.752 - UR system standards

(a) An entity performing UR shall include a physician in any UR program.

(b) An entity performing UR shall develop clinical criteria to be used in making review decisions as follows:

(c) A UR decision denying or approving payment of a service shall be based on the medical necessity and appropriateness of the requested service, the enrollee's individual circumstances, and the applicable contract language concerning benefits and exclusions. UR criteria may not be the sole basis for the decision.

(d) A UR decision denying payment based on medical necessity and appropriateness shall be made by a licensed physician. An approved licensed psychologist may perform UR for a behavioral health care service within the psychologist's scope of practice if the psychologist's clinical experience provides sufficient expertise to review that specific behavioral health care service, and the following standards are satisfied:

(e) An entity performing UR shall notify the health care provider within 48 hours of the request for service of additional facts, documents or information required to complete the UR.

(f) If a UR decision includes a denial, it shall include the contractual basis and clinical reasons for the denial. If a UR decision is a denial, or approves anything less than what was requested, it shall include language informing the enrollee of how to appeal the decision, including location to which the appeal must be sent and time frames.

(g) Copies of written decisions of internal grievance reviews conducted by CREs shall be sent to the plan at the same time the letter is sent to the enrollee, the enrollee's representative, and to the health care provider if the provider filed the grievance with the consent of the enrollee.