§ 69.52. Peer review procedures.
(a) A providers bill shall be referred to a PRO only when circumstances or conditions relating to medical and rehabilitative services provided cause a prudent person, familiar with PRO procedures, standards and practices, to believe it necessary that a PRO determine the reasonableness and necessity of care, the appropriateness of the setting where the care is rendered, and the appropriateness of the delivery of the care. An insurer shall notify a provider, in writing, when referring bills for PRO review at the time of the referral.
(b) An insurer shall make a referral to a PRO within 90 days of the insurers receipt of sufficient documentation supporting the bill. An insurer shall pay bills for care that are not referred to a PRO within 30 days after the insurer receives sufficient documentation supporting the bill. If an insurer makes its referral after the 30th day and on or before the 90th day, the providers bill for care shall be paid.
(c) During an initial determination, a PRO shall request in writing from the provider the records and documents necessary to undertake its review. The PRO shall afford the provider an opportunity to discuss the case with the reviewer and to submit information to the reviewer prior to a final determination.
(d) A PROs initial determination shall be completed within 30 days after the receipt of requested information. When a provider fails to respond to the PROs inquiry or provide requested information, a PRO may commence its review 30 days after the request for information is postmarked. If additional information critical for the outcome of the determination is submitted by a provider or requested by a PRO, the 30-day review period may be tolled up to 20 days for the information to be received and taken into consideration.
(e) A PRO shall provide a written analysis, including specific reasons for its decision, to insurers, which shall within 5 days of receipt, provide copies to providers and insureds. Without the written analysis, the review may not be considered an initial determination and unpaid provider bills subject to the review shall be paid by the insurer. An insurer may request another initial determination if the request is made within 90 days of its receipt of the bill and supporting documentation in accordance with subsection (b). The written analysis of the initial determination shall notify all parties that they have 30 days from the day the initial determination is effected to request a reconsideration and the process and location for filing a request for reconsideration.
(f) A PROs initial determination resulting in the denial of a providers claim, in whole or in part, shall be effected by a licensed practitioner of like speciality or a licensed practitioner with experience providing and prescribing the care subject to the review.
(g) Absent a change of condition, a decision of not medically necessary by the PRO is basis for an insurer to deny payment for similar services to the same insured resulting from the same accident. The insured or subsequent provider has the right to request a reconsideration of the initial determination for subsequent treatment or services received or provided.
(h) An insurer, provider or insured may request, in writing, reconsideration of the initial PRO determination within 30 days from the date the initial determination is effected. A PRO may set a reasonable charge for a reconsideration but the charge for a reconsideration may not exceed the charge for the initial review. An insurer shall make full payment of the charge for reconsideration to the PRO, but the amount paid for the reconsideration shall be ultimately borne by the party against whom a reconsideration determination is made.
(i) A reconsideration shall be effected by a licensed practitioner of like speciality as the provider subject to the reconsideration review. The licensed practitioner effecting the reconsideration review may not be the same licensed practitioner who rendered the PROs initial determination.
(j) A PRO shall afford the party requesting reconsideration an opportunity to discuss the case with the reviewer and to submit additional information identified by the reviewer before making a final determination of the reconsideration.
(k) A reconsideration shall be based upon the information that led to the initial determination, new information found in medical records or additional evidence submitted by the requesting party.
(l) A PRO shall complete a reconsideration within 30 days after receipt of the information submitted under subsection (k). If additional information critical for the outcome of the determination is submitted by a provider or requested by a PRO, the 30-day review period may be tolled up to 20 days for the information to be received and taken into consideration. A PRO shall send written notification of the reconsideration determination to the insurer, which shall within 5 days of receipt provide copies to providers and insureds. The written notice shall contain the basis and rationale for the reconsideration determination.
(m) Upon determination of a reconsideration by a PRO, an insurer, provider or insured may appeal the determination to the courts.
(n) The insured may not be billed during the peer review process.
This section cited in 31 Pa. Code § 69.54 (relating to PRO reporting responsibility); and 31 Pa. Code § 69.55 (relating to criteria for Department approval of a PRO).
Notes of Decisions
Regulations, which permit medical providers to bill insured parties directly for services not paid by their insurer for reason that the insureds policy limits have been exhausted, cure any alleged unconstitutional vagueness in statute. Because either the insurer, a provider or the insured may appeal a private nongovernmental peer review organizations (PRO) determination to court, the process by which permissible charges by a provider are limited does not violate due process. Pennsylvania Medical Providers Association v. Foster, 613 A.2d 51 (Pa. Cmwlth. 1992).
Insured is not required to seek reconsideration of adverse peer review decision under motor vehicle financial responsibility law before initiating action in common pleas court to recover medical benefits under automobile insurance policy. Terminato v. Pennsylvania National Insurance Company, 645 A.2d 1287, 1288 (Pa. 1994); Kuropatwa v. State Farm Insurance Company, 721 A.2d 1067, 1071 (Pa. 1998).
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