OPERATIONAL STANDARDS


§ 9.751. UR system description.

 (a)  An entity performing UR shall have a written UR system description which shall include the following:

   (1)  The scope of the program.

   (2)  The process used in making decisions.

   (3)  The resources used in making decisions.

   (4)  The requirements of this section and of § §  9.752 and 9.753 (relating to UR system standards; and time frames for UR).

 (b)  The entity shall evaluate its UR system annually. The evaluation shall include a report to the board of directors or the quality assurance or quality improvement committee, and shall address the following:

   (1)  The appropriateness of clinical criteria.

   (2)  The consistency of decisionmaking through the conduct of reliability studies of staff application of utilization criteria.

   (3)  Staff resources and training.

   (4)  The timeliness of decisions.

 (c)  The UR system shall include a policy and procedure to enable a health care provider to verify that an individual requesting information for UR purposes is a legitimate representative of the entity.

 (d)  The entity shall ensure that it has sufficient staff, resources and program oversight to ensure adherence to this subchapter, and to section 2152 of the act (40 P. S. §  991.2152).

 (e)  The entity shall make this description available to the Department for review every 3 years or upon request for the conduct of any investigation necessary to determine compliance of the entity with Act 68 and applicable sections of this chapter.

Cross References

   This section cited in 28 Pa. Code §  9.631 (relating to content of an application for an HMO certificate of authority); and 28 Pa. Code §  9.741 (relating to applicability).



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