§ 9.744. CREs participating in internal and external grievance reviews.

 (a)  To be certified to review internal and external grievances, the applicant shall supply the following additional information to the Department for review, along with the application:

   (1)  The name and type of business of each corporation, affiliate or other organization that the applicant controls; the nature and extent of the affiliation or control; and a chart or list clearly identifying the relationship between the applicant and affiliates.

   (2)  The name, title, address and telephone number of a primary and at least one backup designee with whom the Department may communicate regarding assignment of external grievances and other issues.

   (3)  A disclosure of any known potential conflict of interest which would preclude its review of an external grievance—for example, ownership of or affiliation with a competing plan or other health insurance company.

   (4)  A description of the applicant’s:

     (i)   Capacity and procedures for notifying the health care provider of additional facts or documents required to complete the UR within 48 hours of receipt of the request for an expedited review.

     (ii)   Systems and procedures, including staffing and resources, to meet the time frames for decisions as specified in section 2152 of the act (40 P. S. §  991.2152). 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 for internal and external grievance reviews. To be certified, an applicant shall demonstrate it has a contracted and credentialed network of providers, which shall include, at a minimum, all general specialities represented by the American Board Of Medical Specialities (ABMS), the subspecialties of oncology and physician reviewers specializing in transplanation. An applicant shall also provide a description of its ability to obtain within 24 hours the services of a qualified peer reviewer from any speciality or subspecialty required for an external grievance review.

     (iii)   Capability and agreement to receive and decide all external grievances, or just behavioral health grievances if so desired, and the process for ensuring that clinical peer reviewers, when making an external appeal determination concerning medical necessity, consider the clinical standards of the plan, the information provided concerning the enrollee, the attending physician’s recommendation and applicable generally accepted practice guidelines developed by the Federal government, National or professional medical societies, boards and associations.

     (iv)   The capacity, procedures and agreement to maintain the information obtained in the review of the grievances, including outcomes, for at least 3 years in a manner that is confidential and unavailable to any affiliated entity or person who may be a direct or indirect competitor to the plan being reviewed.

     (v)   Fee schedule for the conduct of grievance reviews. An applicant will not be certified as a CRE unless the proposed fees for external reviews are determined to be reasonable by the Department.

   (5)  A certification that the following conditions apply:

     (i)   The CRE is willing and able to participate on a rotational basis in grievance reviews.

     (ii)   Internal and external grievances and expedited grievances will be reviewed and processed in accordance with Act 68 and Subchapter I (relating to complaints and grievances).

 (b)  The Department will add the name of each CRE to its rotational list of CREs certified to conduct external grievances.

Cross References

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

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