§ 9.752. UR system standards.

 (a)  An entity performing UR shall include a physician in any UR program.

 (b)  An entity performing UR shall develop clinical criteria to be used in making review decisions as follows:

   (1)  The clinical criteria shall be developed with input from health care providers in active clinical practice.

   (2)  The clinical criteria shall be reviewed regularly by the entity performing UR and shall be modified to reflect current medical standards.

   (3)  The entity shall make its UR criteria available upon the written request of any health care provider.

 (c)  A UR decision denying or approving payment of a service shall be based on the medical necessity and appropriateness of the requested service, the enrollee’s individual circumstances, and the applicable contract language concerning benefits and exclusions. UR criteria may not be the sole basis for the decision.

 (d)  A UR decision denying payment based on medical necessity and appropriateness shall be made by a licensed physician. An approved licensed psychologist may perform UR for a behavioral health care service within the psychologist’s scope of practice if the psychologist’s clinical experience provides sufficient expertise to review that specific behavioral health care service, and the following standards are satisfied:

   (1)  An approved licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug.

   (2)  The use of a licensed psychologist to perform UR must be approved by the Department as part of the certification process for CREs.

 (e)  An entity performing UR shall notify the health care provider within 48 hours of the request for service of additional facts, documents or information required to complete the UR.

 (f)  If a UR decision includes a denial, it shall include the contractual basis and clinical reasons for the denial. If a UR decision is a denial, or approves anything less than what was requested, it shall include language informing the enrollee of how to appeal the decision, including location to which the appeal must be sent and time frames.

 (g)  Copies of written decisions of internal grievance reviews conducted by CREs shall be sent to the plan at the same time the letter is sent to the enrollee, the enrollee’s representative, and to the health care provider if the provider filed the grievance with the consent of the enrollee.

Cross References

   This section cited in 28 Pa. Code §  9.631 (relating to content of an application for an HMO certificate of authority); 28 Pa. Code §  9.741 (relating to applicability); and 28 Pa. Code §  9.751 (relating to UR system description).

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