§ 9.743. Content of an application for certification as a CRE.

 (a)  A CRE seeking certification shall submit two copies of the Department’s application to the Department’s Bureau of Managed Care.

 (b)  The application shall contain the following:

   (1)  The name, address and telephone number of the applicant as it should appear on the Department’s official list of certified CREs.

   (2)  Information relating to its organization, structure and function, including the following:

     (i)   The location of the principal office handling UR.

     (ii)   The articles of incorporation and bylaws, or similar documents regulating the internal affairs of the applicant.

     (iii)   The name of each owner of more than 5% of the shares of the corporation, if the applicant is a public corporation.

     (iv)   A chart showing the internal organization of the applicant’s management and administrative staff.

   (3)  The names and resumes of each officer, director and senior management.

   (4)  A listing of each plan in this Commonwealth for which the applicant currently conducts UR.

   (5)  A description of the applicant’s:

     (i)   Ability to respond to each telephone call received as required by section 2152 of the act (40 P. S. §  991.2152), including toll-free telephone numbers and the applicant’s system to provide access during nonbusiness hours.

     (ii)   Acceptable selection and credentialing procedures and criteria for physician and psychologist clinical peer reviewers.

     (iii)   Ability to arrange for a wide range of health care providers to conduct reviews. The applicant shall have access to a pool of clinical peer reviewers sufficient to reasonably assure that appropriately qualified reviewers will be available on a timely basis.

     (iv)   Procedures for protecting the confidentiality of medical records and certification that the applicant will comply with the confidentiality provisions in section 2131 of the act (40 P. S. §  991.2131) and other applicable State and Federal laws and regulations imposing confidentiality requirements.

     (v)   Procedures to ensure that a health care provider is able to verify that an individual requesting information on behalf of the plan is a representative of the plan.

     (vi)   Capacity to maintain a written record of UR decisions adverse to enrollees for at least 3 years, including a detailed justification and all required notifications to the health care provider and enrollee.

     (vii)   Evidence of approval, certification or accreditation received by a Nationally recognized accrediting body in the area of UR, if it has secured the approval, certification or accreditation.

     (viii)   The length of time the applicant has been operating in this Commonwealth, if applicable.

     (ix)   A list of three clients, if any, for which the applicant has conducted UR including the name, address, position and telephone number of a contact person for each client. The Department may contact these references for an assessment of the applicant’s past performance and its ability to meet the time frames for prospective, concurrent and retrospective UR in section 2152 of the act (40 P. S. §  991.2152).

 (c)  The applicant shall certify that decisions resulting in a denial shall be made by:

   (1)  A licensed physician.

   (2)  An approved licensed psychologist in a same or similar specialty to the health care provider of the service in question, if the review is of behavioral health care services within the psychologist’s scope of practice, and the psychologist’s clinical experience provides sufficient experience to review that specific behavioral health care service. A licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug.

 (d)  Compensation from a plan to a CRE, employee, consultant or other person performing UR on its behalf does not contain incentives, direct or indirect, to approve or deny payment for the delivery of any health care service. See section 2152(b) of the act (40 P. S. §  991.2152(b)).

 (e)  The Department may request additional information from the applicant necessary to review the application for compliance with Act 68 and this chapter.

Cross References

   This section cited in 28 Pa. Code §  9.741 (relating to applicability).

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