Pennsylvania Code
Title 31 - INSURANCE
Part VIII - Miscellaneous Provisions
Chapter 154 - QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION
REQUIRED PROVISIONS AND ENROLLEE DISCLOSURES
Section 154.11 - Managed care plan requirements
Universal Citation: 31 PA Code ยง 154.11
Current through Register Vol. 54, No. 44, November 2, 2024
(a) Managed care plans shall adopt and maintain procedures by which an enrollee with a life-threatening, degenerative or disabling disease or condition shall, upon request, receive an evaluation, and, if the plan's established standards are met, be permitted to receive approval for either:
(1) A standing referral to a specialist with
clinical expertise in treating the disease or condition.
(2) The designation of a specialist to
provide and coordinate the enrollee's primary and specialty care.
(b) A managed care plan's established standards, as referenced in subsection (a) may include:
(1) Time restrictions on approved treatment
plans, as set forth in section 2111(6) of the act (40 P. S. §
991.2111(6)), which include
standing referrals or specialist designations.
(2) Requirements that treatment plans be
periodically reviewed and reapproved by the plan.
(3) Requirements that the specialist notify
the enrollee's primary care provider of all care provided within 30
days.
Disclaimer: These regulations may not be the most recent version. Pennsylvania may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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