§ 9.711. Informal dispute resolution systems and alternative dispute resolution systems.

 (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.

Authority

   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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