§ 9.753. Time frames for UR.

 (a)  A concurrent UR decision shall be communicated to the plan, the enrollee and the health care provider within 1-business day of the receipt of all supporting information reasonably necessary to complete the review. The plan shall give the enrollee and the health care provider written or electronic confirmation of the decision within 1-business day of communicating the decision.

 (b)  A prospective UR decision shall be communicated to the plan, enrollee and health care provider within 2-business days of the receipt of all supporting information reasonably necessary to complete the review. The plan shall give the enrollee and the health care provider written or electronic confirmation of the decision within 2-business days of communicating the decision.

 (c)  A retrospective UR decision shall be communicated to the plan, the enrollee and the health care provider within 30 days of the receipt of all supporting information reasonably necessary to complete the review. The plan shall give the enrollee and the health care provider written or electronic confirmation of its decision within 15-business days of communicating the decision.

 (d)  A grievance review decision shall comply with the requirements and time frames set out in § §  9.705 and 9.707 (relating to internal grievance process; and external grievance process).

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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