§ 9.705. Internal grievance process.

 (a)  A plan shall establish, operate and maintain an internal enrollee grievance process in compliance with sections 2161 and 2162 of the act (40 P. S. § §  991.2161 and 991.2162) and this subchapter, for the purposes of reviewing a denial of coverage for a health care service on the basis of medical necessity and appropriateness.

 (b)  The enrollee or the enrollee’s representative, or a health care provider with written consent of the enrollee, may file a written grievance with the plan. The plan shall make staff available to record an oral grievance for an enrollee who is unable by reason of disability or language barrier to file a grievance in writing.

 (c)  The plan’s internal grievance process shall include the following standards:

   (1)  First level review.

     (i)   Upon receipt of the grievance, the plan shall provide written confirmation of its receipt to the enrollee and the enrollee’s representative, if the enrollee has designated one, and the health care provider if the health care provider filed the grievance with enrollee consent, and shall also provide the following information:

       (A)   That the plan considers the matter to be a grievance, and that the enrollee, the enrollee’s representative, or health care provider may question this classification by contacting the Department.

       (B)   That the enrollee may appoint a representative to act on the enrollee’s behalf at any time during the internal grievance process.

       (C)   That the enrollee, the enrollee’s representative, or the health care provider that filed the grievance with enrollee consent may review information related to the grievance upon request and submit additional material to be considered by the plan.

       (D)   That the enrollee or the enrollee’s representative may request the aid of a plan employee who has not participated in previous decisions to deny coverage for the issue in dispute, at no charge, in preparing the enrollee’s first level grievance.

       (E)   If the plan chooses to permit attendance at the first level review, that the enrollee, the enrollee’s representative, and the health care provider who filed the grievance, may attend the first level review.

     (ii)   The first level grievance review shall be performed by an initial review committee which shall include one or more individuals selected by the plan. The members of the committee may not have been involved in any prior decision relating to the grievance.

     (iii)   The plan shall provide the enrollee, the enrollee’s representative, or a health care provider that filed a grievance with enrollee consent, access to all information relating to the matter being grieved and shall permit the enrollee, the enrollee’s representative, or the health care provider to provide written data or other material in support of the grievance. The plan may charge a reasonable fee for reproduction of documents. The enrollee, the enrollee’s representative or the health care provider may specify the remedy or corrective action being sought.

     (iv)   The plan shall provide, at no charge, at the request of the enrollee or the enrollee’s representative, a plan employee who has not participated in previous decisions to deny coverage for the issue in dispute, to aid the enrollee or the enrollee’s representative in preparing the enrollee’s grievance.

     (v)   The plan shall complete its review and investigation, and shall arrive at its decision, within 30 days of the receipt of the grievance.

     (vi)   The plan shall notify the enrollee, the enrollee’s representative, and the health care provider if the health care provider filed a grievance with enrollee consent, of the decision of the internal review committee in writing, within 5 business days of the committee’s decision. The notice to the enrollee, the enrollee’s representative, and the health care provider, shall include the basis for the decision and the procedures for the enrollee or provider to file a request for a second level review of the decision of the initial review committee including:

       (A)   A statement of the issue reviewed by the first level review committee.

       (B)   The specific reasons for the decision.

       (C)   References to the specific plan provisions on which the decision is based.

       (D)   If an internal rule, guideline, protocol, or other similar criterion was relied on in making the decision, either the specific rule, guideline, protocol or criterion, or instructions on how to obtain the internal rule, guideline, protocol, or criterion.

       (E)   An explanation of the scientific or clinical judgment for the decision, applying the terms of the plan to the enrollee’s medical circumstances.

       (F)   An explanation of how to file a request for a second level review of the decision of the initial review committee and the time frames for requesting a second level review, if any. See §  9.702(d)(1) (relating to complaints and grievances).

   (2)  Second level review.

     (i)   Upon receipt of the request for a second level review, the plan shall send the enrollee, the enrollee’s representative, and the health care provider, if the health care provider filed the grievance with enrollee consent, an explanation of the procedures to be followed during the second level review. This information shall include the following:

       (A)   A statement that, and an explanation of how, the enrollee or the enrollee’s representative may request the aid of a plan employee at no charge, who has not participated in previous decisions to deny coverage for the issue in dispute, in preparing the enrollee’s second level grievance.

       (B)   Notification that the enrollee and the enrollee’s representative, and the health care provider, if the health care provider filed the grievance with enrollee consent, have the right to appear before the second level review committee and that the plan will provide the enrollee and the enrollee’s representative, and the health care provider with 15 days advance written notice of the time scheduled for that review.

     (ii)   The second level review committee shall be made up of three or more individuals who did not previously participate in the decision to deny coverage or payment for health care services. The members of the second level review committee shall have the duty to be impartial in their review and decision.

     (iii)   The second level review shall satisfy the following:

       (A)   The enrollee, the enrollee’s representative, and the health care provider, if the health care provider filed the grievance with enrollee consent, shall have the right to be present at the second level review, and to present a case.

       (B)   The plan shall notify the enrollee, the enrollee’s representative, and the health care provider at least 15 days in advance of the date scheduled for the second level review.

       (C)   The plan shall provide reasonable flexibility in terms of time and travel distance when scheduling a second level review to facilitate the attendance of the enrollee, the enrollee’s representative, and the health care provider. The plan shall make reasonable accommodation to facilitate the participation of the enrollee and the enrollee’s representative, and the health care provider, if the provider has filed the grievance with enrollee consent, by conference call or in person and shall take into account the enrollee’s and the enrollee’s reresentative’s access to transportion and any disabilities that may impede or limit the enrollee’s ability to travel.

       (D)   If an enrollee or the enrollee’s representative, or the health care provider if the health care provider filed the grievance with the enrollee’s consent, cannot appear in person at the second level review, the plan shall provide the enrollee and the enrollee’s representative or the health care provider the opportunity to communicate with the review committee by telephone or other appropriate means.

       (E)   Attendance at the second level review shall be limited to members of the review committee; the enrollee, or the enrollee’s representatives, including any legal representative or attendant necessary for the enrollee to participate in or understand the proceedings, or both; the health care provider if the health care provider filed the grievance with enrollee consent; applicable witnesses; and appropriate representatives of the plan. Persons attending and their respective roles at the review shall be identified for the enrollee and the enrollee’s representative.

       (F)   The plan shall provide, at no charge, at the request of the enrollee or the enrollee’s representative, a plan employee, who has not participated in previous decisions to deny coverage for the issue in dispute, to aid the enrollee or the enrollee’s representative in preparing the enrollee’s second level grievance.

       (G)   Committee proceedings at the second level review shall be informal and impartial to avoid intimidating the enrollee or the enrollee’s representative.

       (H)   The committee may not discuss the case to be reviewed prior to the second level review meeting.

       (I)   A committee member who does not personally attend the review meeting may not vote on the case unless that person actively participates in the review meeting by telephone or videoconference, and has the opportunity to review any additional information introduced at the review meeting prior to the vote.

       (J)   The plan may provide an attorney to represent the interests of the committee and to ensure the fundamental fairness of the review and that all disputed issues are adequately addressed. In the scope of the attorney’s representation of the committee, the attorney representing the committee may not argue the plan’s position, or represent the plan or plan staff.

       (K)   The committee may question the enrollee and the enrollee’s representative, the health care provider if the provider filed the grievance with enrollee consent, and plan staff representing the plan’s position.

       (L)   The committee shall base its decision solely upon the materials and testimony presented at the review. The committee may not base its decision upon any document obtained on behalf of the plan which sets out medical policies, standards or opinions or specifies opinions supporting the decision of the plan unless the plan has made available for questioning by the review committee or the enrollee, in person or by telephone, an individual, of the plan’s choice, who is familiar with the policies, standards or opinions set out in the document.

     (iv)   The proceedings of the second level review committee, including the enrollee’s comments and the comments of the enrollee’s representatives and the health care provider if the provider filed the grievance with enrollee consent shall be either transcribed verbatim, summarized, or recorded electronically, and maintained as a part of the grievance record to be forwarded upon a request for an external grievance review.

     (v)   The plan shall complete the second level grievance review and arrive at its decision within 45 days of receipt of the request for the review.

     (vi)   The plan shall notify the enrollee, the enrollee’s representative, and in the case of a grievance filed by a health care provider, the provider, of the decision of the second level review committee in writing within 5 business days of the committee’s decision.

     (vii)   The plan shall include the basis for the decision and the procedures for the enrollee and the enrollee’s representative or the health care provider to file a request for an external grievance review in its response to the enrollee, the enrollee’s representative or health care provider, if the health care provider filed the grievance with the enrollee’s consent including the following:

       (A)   A statement of the issue reviewed by the second level review committee.

       (B)   The specific reasons for the decision.

       (C)   References to the specific plan provisions on which the decision is based.

       (D)   If an internal rule, guideline, protocol, or other similar criterion was relied on in making the decision, either the specific rule, guideline, protocol or criterion, or instructions on how to obtain the internal rule, guideline, protocol, or criterion.

       (F)   An explanation of the scientific or clinical judgment for the decision, applying the terms of the plan to the enrollee’s medical circumstances.

       (G)   An explanation of how to request an external grievance review.

       (H)   The time frames for the enrollee and the enrollee’s representative, or the health care provider to file a request for an external grievance review. See §  9.707(b)(1) (relating to external grievance process).

   (3)  Same or similar specialty.

     (i)   Both the initial and second level grievance review shall include a licensed physician or an approved licensed psychologist, in the same or similar specialty as that which would typically manage or consult on the health care service in question.

     (ii)   The physician or approved licensed psychologist, in the same or similar specialty, need not personally attend at the review, but shall be included in the review meeting and discussion by written report, telephone or videoconference. A licensed physician or approved licensed psychologist who does not personally attend the review meeting may not vote on the grievance, unless that person actively participates in the review meeting by telephone or videoconference and has the opportunity to review any additional information introduced at the review meeting prior to the vote. A licensed physician or approved licensed psychologist not voting on the grievance shall provide input by written report as stated in subparagraph (iii).

     (iii)   If the licensed physician or approved licensed psychologist, in the same or similar specialty, will not be present or included by telephone or videoconference at the review attended by the enrollee or health care provider, the plan shall notify the enrollee, the enrollee’s representative, and the health care provider, if the health care provider filed the grievance with the enrollee’s consent, of that fact in advance of the review and of the right of the enrollee and the enrollee’s representative, and the health care provider, if the health care provider filed the grievance with the enrollee’s consent, to request a copy of the written report of the licensed physician or approved licensed psychologist. The plan shall provide the enrollee and the enrollee’s representative, and the health care provider who filed the grievance with enrollee consent, upon written request, a copy of the report of the licensed physician or approved licensed psychologist at least 7 days prior to the review date.

     (iv)   The plan shall include in the report in subparagraphs (ii) and (iii) the credentials of the licensed physician or approved licensed psychologist reviewing the case. If the licensed physician or approved licensed psychologist is included in the review in subparagraph (ii), a copy of the credentials of the physician or approved licensed psychologist shall be provided to the enrollee, the enrollee’s representative and to the health care provider, if the health care provider filed the grievance.

     (v)   For purposes of this section, if a specialist who is a physician or psychologist is requesting the health care service in dispute, the reviewing physician or psychologist must be a specialist in the same or similar specialty.

Cross References

   This section cited in 28 Pa. Code §  9.709 (relating to expedited review); and 28 Pa. Code §  9.753 (relating to time frames for UR).



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