§ 9.683. Standing referrals or specialists as primary care providers.

 (a)  A plan shall adopt and maintain procedures whereby an enrollee with a life-threatening, degenerative or disabling disease or condition shall, upon request, receive an evaluation by the plan and, if the plan’s established standards are met, the procedures shall allow for the enrollee to receive either a standing referral to a specialist with clinical expertise in treating the disease or condition, or the designation of a specialist to assume responsibility to provide and coordinate the enrollee’s primary and specialty care.

 (b)  The plan’s procedures shall:

   (1)  Ensure the plan has established standards, including policies, procedures and clinical criteria for conducting the evaluation and issuing or denying the request, including a process for reviewing the clinical expertise of the requested specialist. The plan shall have its standards approved by its quality improvement or quality assurance committee.

   (2)  Provide for evaluation by appropriately trained and qualified personnel.

   (3)  Include a treatment plan approved by the plan in consultation with the primary care provider, the enrollee and as appropriate, the specialist, and provided in writing to the specialist who will be serving as the primary care provider or receiving the standing referral.

   (4)  Be subject to the plan’s utilization management requirements and other established utilization management and quality assurance criteria.

   (5)  Ensure that a standing referral to, or the designation of a specialist as, a primary care provider will be made to participating health care providers when possible.

   (6)  Ensure the plan issues a written decision regarding the request for a standing referral or designation of a specialist as a primary care provider within a reasonable period of time taking into account the nature of the enrollee’s condition, but within 45 days after the plan’s receipt of the request.

   (7)  Ensure the written decision denying the request provides information about the right to appeal the decision through the grievance process.

 (c)  A plan shall have mechanisms in place to review the effect of this procedure, and shall present the results to its quality improvement or quality assurance committee on an annual basis.

Cross References

   This section cited in 28 Pa. Code §  9.678 (relating to PCPs).



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