§ 9.706. Health care provider initiated grievances.

 (a)  A health care provider may, with the written consent of an enrollee that meets the requirements of subsection (g), file a written grievance with a plan.

 (b)  A health care provider may obtain written consent from an enrollee or the enrollee’s legal representative to pursue a grievance in lieu of the enrollee at the time of treatment. A health care provider may not require an enrollee or the enrollee’s legal representative to sign a document authorizing the health care provider to file a grievance as a condition of providing a health care service.

 (c)  Once a health care provider assumes responsibility for filing a grievance, the health care provider may not bill the enrollee or the enrollee’s legal representative for services provided that are the subject of the grievance until the external grievance review has been completed or the enrollee or the enrollee’s legal representative rescinds consent for the health care provider to pursue the grievance. If the health care provider chooses never to bill the enrollee or the enrollee’s legal representative for the services provided that are the subject of the grievance, the health care provider may drop the grievance with notice to the enrollee and the enrollee’s legal representative in accordance with subsection (g).

 (d)  If the health care provider elects to appeal an adverse decision of a CRE, the health care provider may not bill the enrollee or the enrollee’s legal representative for services provided that are the subject of the grievance until the health care provider chooses not to appeal an adverse decision to a court of competent jurisdiction.

 (e)  The consent of an enrollee or the enrollee’s legal representative to a health care provider to pursue a grievance shall be in writing, shall be automatically rescinded upon the failure of the health care provider to file or pursue a grievance under this subchapter and shall include each of the following elements:

   (1)  The name and address of the enrollee and of the policy holder, if they are different, the enrollee’s date of birth and the enrollee’s identification number.

   (2)  If the enrollee is a minor, or is legally incompetent, the name, address and relationship to the enrollee of the person who signs the consent for the enrollee.

   (3)  The name, address and plan identification number of the health care provider to whom the enrollee is providing the consent.

   (4)  The name and address of the plan to which the grievance will be submitted.

   (5)  An explanation of the specific service for which coverage was provided or denied to the enrollee to which this consent will apply.

   (6)  The following statements:

     (i)   The enrollee or the enrollee’s representative may not submit a grievance concerning the services listed in this consent form unless the enrollee or the enrollee’s legal representative rescinds consent in writing. The enrollee or the enrollee’s legal representative has the right to rescind a consent at any time during the grievance process.

     (ii)   The consent of the enrollee or the enrollee’s legal representative shall be automatically rescinded if the provider fails to file a grievance, or fails to continue to prosecute the grievance through the second level review process.

     (iii)   The enrollee or the enrollee’s legal representative, if the enrollee is a minor or is legally incompetent, has read, or has been read this consent form, and has had it explained to his satisfaction. The enrollee or the enrollee’s legal representative understands the information in the enrollee’s consent form.

   (7)  The dated signature of the enrollee, or the enrollee’s legal representative, and the dated signature of a witness.

 (f)  The enrollee may rescind consent to a health care provider, to file a grievance on behalf of the enrollee, at any time during the grievance process. If the enrollee rescinds consent, the enrollee may continue with the grievance at the point at which consent was rescinded. The enrollee may not file a separate grievance. An enrollee who has filed a grievance may, at any time during the grievance process, choose to provide consent to a health care provider to continue with the grievance instead of the enrollee. The legal representative of the enrollee may exercise the rights conferred upon the enrollee by this subsection.

 (g)  The provider, having obtained consent from the enrollee or the enrollee’s legal representative to file a grievance, shall have 10 days from receipt of the standard written UR denial and any decision letter from a first, second or external review upholding the plan’s decision to notify the enrollee or the enrollee’s legal representative of its intention not to pursue a grievance.

Cross References

   This section cited in Pa. Code §  9.702 (relating to complaints and grievances).



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