S0225B0453A01850 LKK:JMT 06/21/21 #90 A01850
AMENDMENTS TO SENATE BILL NO. 225
Sponsor: SENATOR PHILLIPS-HILL
Printer's No. 453
Amend Bill, page 1, lines 1 through 22, by striking out all
of said lines and inserting
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," in quality healthcare
accountability and protection, further providing for
definitions and for responsibilities of managed care plans,
providing for preauthorization review standards and for
preauthorization costs, further providing for continuity of
care, providing for step therapy, further providing for
required disclosure and for operational standards and
providing for initial review of preauthorization requests and
adverse determinations, for preauthorization denial
grievances and for access requirements in service areas; and
making an editorial change.
Amend Bill, page 1, lines 25 through 27; pages 2 through 32,
lines 1 through 30; page 33, lines 1 through 23; by striking out
all of said lines on said pages and inserting
Section 1. The definitions of "emergency service,"
"grievance," "health care service," "prospective utilization
review," "retrospective utilization review," "utilization
review" and "utilization review entity" in section 2102 of the
act of May 17, 1921 (P.L.682, No.284), known as The Insurance
Company Law of 1921, are amended and the section is amended by
adding definitions to read:
Section 2102. Definitions.--As used in this article, the
following words and phrases shall have the meanings given to
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them in this section:
* * *
"Administrative defect." Any deficiency, error, mistake or
missing information other than medical necessity or an uncovered
benefit that serves as the basis of an adverse determination
issued by a utilization review entity as justification to deny
prior utilization review or preauthorization.
"Adverse determination." The following shall apply:
(1) A decision made by a utilization review entity following
a preauthorization request that denies coverage for one or more
the following reasons:
(i) The health care service requested through
preauthorization are not medically necessary.
(ii) The preauthorization or prior utilization review
request contains an administrative defect.
(iii) The health care services requested through
preauthorization are subject to the benefit coverage of a
managed care plan that has been denied, modified or terminated
either prior to the request for preauthorization or as a result
of the requested preauthorization.
(2) The term includes a decision to deny a step therapy
exception request under section 2118.
(3) The term does not include a decision to deny, reduce or
terminate services that are not covered for reasons other than
medical necessity, experimental or investigational nature.
* * *
"Authorization." A determination by a managed care plan or
utilization review entity that:
(1) A health care service has been reviewed and, based on
the information provided, is medically necessary.
(2) The health care service reviewed is a covered service
under the plan.
(3) Payment will be made for the health care service subject
to copay, deductible and health care network restrictions.
* * *
"Clinical criteria." Policies, screening procedures,
determination rules, determination abstracts, clinical
protocols, practice guidelines and medical protocols that are
specified in a written document available for peer-to-peer
review by a peer within the same profession and specialty and
subject to challenge by an enrollee, a provider or a provider
organization when used as a basis to withhold preauthorization,
deny or otherwise modify coverage and that is used by a
utilization review entity to determine the medical necessity of
health care services. The criteria shall:
(1) Be based on nationally recognized standards.
(2) Be developed in accordance with the current standards of
national accreditation entities.
(3) Reflect community standards of care.
(4) Ensure quality of care and access to needed health care
services.
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(5) Be evidence-based or based on generally accepted expert
consensus standards.
(6) Be sufficiently flexible to allow deviations from the
standards when justified on a case-by-case basis.
(7) Be evaluated and updated annually.
* * *
"Emergency service." Any health care service provided to an
enrollee, including prehospital transportation or treatment by
emergency medical services providers, after the sudden onset of
a medical condition that manifests itself by acute symptoms of
sufficient severity or severe pain such that a prudent layperson
who possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in:
(1) placing the health of the enrollee or, with respect to a
pregnant woman, the health of the woman or her unborn child in
serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
Emergency transportation and related emergency service provided
by a licensed ambulance service shall constitute an emergency
service.
* * *
"Final adverse determination." An adverse determination that
has been upheld by a utilization review entity or managed care
plan at the completion of the internal grievance process.
"Grievance." As provided in subdivision (i), a request by an
enrollee or a health care provider, with the written consent of
the enrollee, to have a managed care plan or utilization review
entity reconsider a decision solely concerning the medical
necessity [and appropriateness] of a health care service. If the
managed care plan is unable to resolve the matter, a grievance
may be filed regarding the decision that:
(1) disapproves full or partial payment for a requested
health care service;
(2) approves the provision of a requested health care
service for a lesser scope or duration than requested; or
(3) disapproves payment for the provision of a requested
health care service but approves payment for the provision of an
alternative health care service.
The term does not include a complaint.
* * *
"Health care service." Any [covered] treatment, admission,
procedure, test used to aid in diagnosis or the provisions of
the applicable treatment, pharmaceutical product, medical
supplies and equipment or other services, including behavioral
health[, prescribed or otherwise] provided or proposed to be
provided by a health care provider to an enrollee under a
managed care plan contract.
* * *
"Medically necessary health care services" or "medically
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necessary." Health care services that a prudent health care
provider would provide to a patient for the purpose of
preventing, diagnosing or treating an illness, injury, disease
or its symptoms in a manner that meets all the following:
(1) In accordance with generally accepted standards of
medical practice based on clinical criteria.
(2) Appropriate in terms of type, frequency, extent, site
and duration in accordance with clinical criteria.
"Nonurgent health care service." A health care service
provided to an enrollee that is not considered an emergency
service or an urgent health care service.
* * *
"Prospective utilization review[.]," "preauthorization" or
"prior authorization." A review by a utilization review entity
of all reasonably necessary supporting information that occurs
prior to the delivery or provision of a health care service and
results in a decision to approve or deny payment for the health
care service.
* * *
"Retrospective utilization review[.]" or "retrospective
review." A review by a utilization review entity of all
reasonably necessary supporting information which occurs
following delivery or provision of a health care service and
results in a decision to approve or deny payment for the health
care service.
* * *
"Urgent health care service." The following shall apply:
(1) A health care service deemed by a provider to require
expedited preauthorization review in the event a delay may
jeopardize life or health of the enrollee or a delay in
treatment could do any of the following:
(i) Negatively affect the ability of the enrollee to regain
maximum function.
(ii) Subject the enrollee to severe pain that cannot be
adequately managed without receiving the care or treatment that
is the subject of the utilization review as quickly as possible.
(2) The term does not include an emergency service or
nonurgent health care service.
"Utilization review." A system of prospective, concurrent or
retrospective utilization review performed by a utilization
review entity of the medical necessity [and appropriateness] of
health care services prescribed, provided or proposed to be
provided to an enrollee. The term does not include any of the
following:
(1) Requests for clarification of coverage, eligibility or
health care service verification.
(2) A health care provider's internal quality assurance or
utilization review process unless the review results in denial
of payment for a health care service.
"Utilization review entity." Any entity certified pursuant
to subdivision (h) that performs utilization review on behalf of
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a managed care plan. The term includes all the following:
(1) An insurer that writes health insurance policies,
including preferred provider organizations as defined in section
630.
(2) Pharmacy benefits managers responsible for managing
access of enrollees to available pharmaceutical or
pharmacological care.
(3) A health insurer if the health insurere performs
utilization review.
Section 2. Section 2111(3) of the act is amended and the
section is amended by adding paragraphs to read:
Section 2111. Responsibilities of Managed Care Plans.--A
managed care plan shall do all of the following:
* * *
(3) [Adopt and maintain a definition of medical necessity
used by the plan in determining health care services.]
Establish an electronic platform and process for the submission
and receipt of prior authorization requests by network
providers. The following shall apply:
(i) Each managed care plan must provide written instructions
and training to network providers who may submit requests using
the electronic platform that set forth protocols addressing
submission of preauthorization requests if any of the following
apply:
(A) The electronic platform is not available due to
technological failure or electronic failure.
(B) Documents requested by the managed care plan or
utilization review entity exceed the submission capacity
limitations of the electronic platform.
(ii) Each managed health care plan shall establish mutually
agreeable terms for submission of preauthorization requests and
communication regarding preauthorization in circumstances where
a network provider or health care facility does not have either
of the following:
(A) Internet access.
(B) An electronic health record systems.
* * *
(14) Publish available health care services subject to prior
authorization on its publicly accessible Internet website in an
easily accessible manner and shall provide the information upon
request of a participating network provider.
(15) Provide sixty (60) days notice to participating network
providers of any changes to existing prior authorization
criteria or implementation of new prior authorization
requirements.
(16) Establish a protocol to obtain an exception from any
step therapy requirements and publish that process in an easily
accessible manner on its publicly accessible Internet website.
(17) Provide the rules and criteria related to the step
therapy protocol upon request to all prescribing network
providers.
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Section 3. The act is amended by adding sections to read:
Section 2114. Preauthorization Review Standards.--(a)
Preauthorization approval requests may be submitted
electronically through a secure electronic transmission platform
established and maintained by a managed care plan under section
2111(3). An electronic submission shall not be required in
circumstances where the managed care plan has not published
protocols or provided training as required by section 2111(3).
(b) Any restriction that a utilization review entity places
on the preauthorization of health care services shall be in
accordance with the following:
(1) Based on the medical necessity of those services and on
any additional clinical criteria information submitted by the
provider seeking authorization of the health care service on
behalf of the enrollee.
(2) Applied consistently.
(3) Disclosed by the managed care plan or utilization review
entity under sections 2111 and 2136.
(c) Adverse determinations and final adverse determinations
made by a utilization review entity or agent thereof shall be
based on medical necessity and supporting clinical criteria
submitted by the provider seeking authorization for the health
care service on behalf of the enrollee.
(d) A utilization review entity shall not deny coverage of a
health care service solely based on the grounds that the health
care service does not meet clinical criteria.
(e) Preauthorization shall not be required in any of the
following:
(1) If a prescribed medication is a noncontrolled generic
medication.
(2) If a procedure to be performed is customary and properly
indicated or is a treatment for the clinical indication as
supported by peer-reviewed medical publications.
(3) For the provision of MAT for the treatment of an opioid-
use disorder.
(f) If a provider contacts a utilization review entity
seeking preauthorization for a medically necessary health care
service under section 2111(14) and the utilization review
entity, through an agent, contractor, employe or representative
informs the provider that preauthorization is not required for
the health care service subject to the request, coverage for the
service shall be deemed approved.
Section 2115. Preauthorization Costs.--(a) In the event
that an insured is covered by more than one health plan that
requires preauthorization:
(1) A secondary managed health care plan shall not deny
preauthorization for a health care service solely on the basis
that the preauthorization procedures of the secondary insurer
were not followed if the enrollee subject to the plan received
preauthorization from the enrollee's primary managed health care
plan.
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(2) Nothing in this section shall be construed to preclude a
secondary insurer from requiring preauthorization for a health
care service denied preauthorization by a primary insurer.
(b) Any internal grievance or internal review of an adverse
determination of a final adverse determination shall be provided
without charge to the enrollee or enrollee's health care
provider.
Section 4. Section 2117 of the act is amended by adding
subsections to read:
Section 2117. Continuity of Care.--* * *
(g) If the appeal of an adverse determination from a
preauthorization request concerns ongoing health care services
provided under an initially authorized admission or course of
treatment, the health care services shall continue to be
provided to the enrollee and paid for by the managed care plan
without liability to the enrollee or the enrollee's health care
provider for no less than sixty (60) days.
(h) The managed care plan or utilization review entity shall
not be permitted to retroactively review the decision to
authorize and provide health care services through
preauthorization, including preauthorization for extending the
term or course of treatment unless the managed care plan or
utilization review entity can demonstrate by clear and
convincing evidence that preauthorization was authorized using
knowingly inaccurate clinical information submitted by the
provider or fraud.
(i) Notwithstanding any other provision of law, the managed
care plan shall not retroactively recover the cost of treatment
either for the initial period of treatment subject to
preauthorization or the period of treatment provided to the
enrollee as part of the preauthorization decision-making process
to authorize coverage of additional treatment periods.
(j) Continued care shall not be subject to concurrent review
if the treatment regimen or continuity of care follows from a
authorizing previous preauthorization request unless the managed
care plan or utilization review entity can demonstrate by clear
and convincing evidence that preauthorization was authorized
using knowingly inaccurate clinical information submitted by the
provider or fraud.
Section 5. The act is amended by adding a section to read:
Section 2118. Step Therapy.--(a) (1) When coverage of a
prescription drug for the treatment of any medical condition is
restricted for use by a managed care plan or utilization review
entity through a step therapy protocol, the enrollee and
provider shall have access to a clear, readily accessible and
convenient process to request a step therapy exception under
section 2111(16). Failure of the managed care plan to meet its
obligation under section 2111 shall result in all step therapy
exceptions being deemed approved until the managed care plan
complies with the requirements of section 2111(16).
(2) No step therapy shall be required if the medication
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being prescribed is being prescribed in response to an
emergency.
(3) A step therapy exception shall be granted if any of the
following apply:
(i) The required prescription drug is contraindicated, not
in the best interest of the enrollee or will likely cause an
adverse reaction by or physical or mental harm to the enrollee.
(ii) The required prescription drug is expected to be
ineffective based on the known clinical characteristics of the
enrollee and the known characteristics of the prescription drug
regimen.
(iii) The enrollee has tried the required prescription drug
while under the enrollee's current or previous health care plan
or health benefit plan, or another prescription drug in the same
pharmacologic class or with the same mechanism of action, and
the prescription drug was discontinued due to lack of efficacy
or effectiveness, diminished effect or an adverse event.
(iv) The enrollee is stable on a prescription drug
previously selected by the enrollee's provider and previously
approved by a managed care plan or utilization review entity.
(4) Granting the step therapy exception shall authorize
coverage for the prescription drug prescribed by the enrollee's
treating health care provider.
(b) Step therapy exception requests or an appeal thereof
shall be granted or denied within five (5) business days of
receipt, subject to the following:
(1) In cases where the requested exception is related to an
urgent healthcare treatment, the managed care plan or
utilization review entity evaluating the exception shall respond
within twenty-four (24) hours of receipt of the request.
(2) If a request for an exception under this section is
incomplete or additional clinically relevant information is
required, the managed care plan or utilization review entity
shall notify the prescribing practitioner within five (5)
business days of submission, or twenty-four (24) hours in an
urgent health care request, that additional or clinically
relevant information is required in order to approve or deny the
step therapy exception request or appeal under this section. The
request for additional information may only extend the deadlines
herein an additional forty-eight (48) hours for nonurgent
healthcare services subject to step therapy.
(c) If a determination is not rendered within the applicable
deadlines, the requested exception shall be deemed approved, and
treatment authorized. In a circumstance where the exception has
been deemed approved and treatment has been authorized shall not
be subject to concurrent review or retroactive review because of
the failure of the managed care plan to render a determination
under this section.
(d) In the event of a denial, the managed care plan or
utilization review entity shall inform the enrollee of the right
to a grievance process. This subsection shall not be construed
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to prevent:
(1) A managed care plan or utilization review entity from
requiring a pharmacist to effect substitutions of prescription
drugs consistent with the laws of this Commonwealth.
(2) A health care provider from prescribing a prescription
drug that is determined to be medically appropriate.
(e) As used in this section, the following words and phrases
shall have the meanings given to them in this section:
"Step therapy exception." When a step therapy protocol should
be overridden in favor of immediate coverage of the health care
provider's selected prescription drug.
"Step therapy protocol." A protocol, policy or program that
establishes the specific sequence in which prescription drugs
for a specified medical condition and medically appropriate for
a particular patient are covered by an insurer or health plan.
Section 6. Article XXI, Subdivision (f) heading of the act
is amended to read:
(f) Information for Enrollees and Health Care Providers.
Section 7. Section 2136 of the act is amended by adding a
subsection to read:
Section 2136. Required Disclosure.--* * *
(c) If either a managed care plan or utilization review
entity intends to implement a new preauthorization requirement
or restriction or amend an existing requirement or restriction,
the managed care plan or utilization review entity shall provide
network providers and enrollees with written notice of the new
or amended requirement or amendment not less than sixty (60)
days before implementation. The notice shall be in writing which
may be satisfied by any of the following:
(1) Mail through the United States Postal Service.
(2) Electronic mail read receipt requested.
(3) Publication on the publicly accessible Internet website
of the managed care plan or utilization review entity with an
electronic mail message to network providers and enrollees that
identifies the location of the publication on the website.
(4) Web-exchange, provided that an electronic mail message
on how to access the web-exchange is sent to network providers
and enrollees.
(5) Any other contractually agreed upon method, specifying
the details of the communication which include some proof of
receipt by the network providers and enrollees.
Section 8. Section 2152(a)(4) and (6) of the act are
amended, subsection (a) is amended by adding paragraphs and the
section is amended by adding a subsection to read:
Section 2152. Operational Standards.--(a) A utilization
review entity shall do all of the following:
* * *
(4) Conduct utilization reviews based on the medical
necessity [and appropriateness] of the health care service being
reviewed and provide notification within the following time
frames:
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(i) [A prospective utilization review decision shall be
communicated within two (2) business days of the receipt of all
supporting information reasonably necessary to complete the
review.] A prospective utilization review or preauthorization
decision shall be rendered not more than seven (7) days after
initial submission of the request for authorization. The
decision to authorize or deny the requested health care service
shall be communicated within five (5) business days of the
receipt of all supporting information reasonably necessary to
complete the review. If the initial submission does not contain
all of the supporting information reasonably necessary to
complete the review, the utilization review entity may request
additional information from the provider but the request shall
only extend the seven (7) day deadline for a decision either
authorizing or denying the health care service an additional
forty-eight (48) hours.
(ii) A concurrent utilization review decision shall be
communicated within one (1) business day of the receipt of all
supporting information reasonably necessary to complete the
review.
(iii) A retrospective utilization review decision shall be
communicated within thirty (30) days of the receipt of all
supporting information reasonably necessary to complete the
review. Utilization review entities shall not retroactively
review the medical necessity of a preauthorization that has been
previously approved or granted under section 2117.
(iv) A utilization review entity shall allow an enrollee and
the enrollee's health care provider a minimum of one (1)
business day following an inpatient admission under emergency
health care service or urgent health care service to notify the
utilization review entity of the admission and any health care
services performed.
* * *
(6) Provide all decisions in writing to include the basis
and clinical rationale for the decision. For adverse
determinations from preauthorization requests, a utilization
review entity shall provide notice of all adverse determinations
to the enrollee and the enrollee's health care provider. The
notice of adverse determination shall include instructions
concerning how a grievance may be filed for an adverse
determination based on medical necessity. If the adverse
determination is based on an administrative defect, the
determination shall provide information on how the defect may be
cured and instructions for resubmitting the preauthorization
request.
* * *
(9) Post the following to the utilization review entity's
publicly accessible Internet website:
(i) A current list of services and supplies requiring
preauthorization.
(ii) Written clinical criteria for preauthorization
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decisions.
(10) Ensure that a preauthorization shall be valid for no
longer than one hundred eighty (180) days or the duration of
treatment, whichever is greater, from the date the health care
provider receives the preauthorization so long as the enrollee
is a member of the plan.
(11) When performing preauthorization, only request copies
of medical records relevant to determining the medical necessity
of a health care service requested.
(12) In the event an administrative defect is discovered, a
managed care plan shall allow a health care provider the
opportunity to remedy the administrative defect within forty-
eight hours (48) hours of receiving notice of the defect. If a
health care provider remedies the administrative defect, a
determination of preauthorization shall be rendered within
forty-eight (48) hours. If the administrative defect remains
uncured, the managed care plan may deny preauthorization.
* * *
(e) Failure by a utilization review entity to comply with
deadlines and other requirements specified for preauthorization
shall result in the requested preauthorization for the health
care service to be deemed authorized and paid by the managed
care plan. Failure of the provider cure any administrative
defects in preauthorization requests in a timely manner under
this section may result in the preauthorization being denied.
Section 9. The act is amended by adding sections to read:
Section 2161.1. Initial Review of Preauthorization Requests
and Adverse Determinations.--(a) A utilization review entity
shall ensure that:
(1) A denial based on the medical necessity of a
preauthorization request is made by a qualified licensed health
care provider who has knowledge of the items, services,
products, tests or procedures submitted for preauthorization.
(2) If an adverse determination is made by a physician and
based on medical necessity, then the physician must possess a
current and valid nonrestricted license to practice medicine in
this Commonwealth and be board certified. If the
preauthorization review requires a peer-to-peer review in the
specialty or subspecialty where a review is requested by the
submitting provider, then the physician conducting the review on
behalf of the utilization review entity shall be of a similar
specialty to the health care service for which preauthorization
is requested.
(b) Notification of a preauthorization shall be accompanied
by a unique preauthorization number and indicate:
(1) The specific health care services preauthorized.
(2) The next date for review.
(3) The date of admission or initiation of services, if
applicable.
(c) In the event a health care provider obtains
preauthorization for one (1) service but the service provided is
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not an exact match to the service that was preauthorized a
utilization review entity or managed care plan shall grant
authorization for the health care service provided and remit
payment at a rate of reimbursement that is associated with
either the preauthorized health care service or the service
appropriately substituted based on common procedural terminology
and clinical criteria.
(d) (1) If a utilization review entity challenges the
medical necessity of a health care service, the utilization
review entity shall notify the enrollee's health care provider
that medical necessity is being challenged and provide the basis
of the challenge in sufficient detail to allow the provider
requesting authorization of the health care service to
meaningfully address the challenge raised by the utilization
review entity prior to issuing an adverse determination.
(2) The enrollee's health care provider or designee and the
enrollee or enrollee's designee shall have the right to discuss
the medical necessity of the health care service with the
utilization review physician.
(3) A utilization review entity questioning medical
necessity of a health care service which may result in an
adverse determination shall ensure a reviewing physician making
the decision is available telephonically at a specifically
appointed mutually agreeable time scheduled in advance between
the provider requesting the health care service and reviewing
physician between the hours of seven (7) o'clock antemeridian
and seven (7) o'clock postmeridian. If the utilization review
entity fails to make the reviewing physician available as
required by this paragraph, the health care service subject to
the preauthorization request shall be deemed authorized.
(e) When making a determination based on medical necessity,
a utilization review entity shall base the determination on an
enrollee's presenting symptoms, diagnosis and information
available through the course of treatment or at the time of
admission. Such information may also include any medical
information collected at the time the enrollee presented to the
emergency department if the information is relevant to the
determination.
(f) In the event a utilization review entity determines an
alternative level of care is appropriate, the utilization review
entity shall provide notice of the alternative level of care to
the provider requesting preauthorization for a health care
service and cite the specific criteria used as the basis for the
alternative level of care determination to the health care
provider prior to denying preauthorization. An alternative level
of care decision shall be subject to a peer-to-peer review as
under this section.
(g) A utilization review entity may not issue an adverse
determination for a procedure due to lack of preauthorization if
the procedure is medically necessary or clinically appropriate
for the patient's medical condition and rendered at the same
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time as a related procedure for which preauthorization was
required and received.
(h) A utilization review entity shall make a
preauthorization adverse determination decision and notify the
enrollee and the enrollee's health care provider as follows:
(1) For nonurgent health care services, within five (5) days
of obtaining all the necessary information to make the
preauthorization or adverse determination, so long as the entire
review process is completed either seven (7) days following the
initial request if no additional information is requested by the
utilization review entity or nine (9) days following the initial
submission if additional information is requested.
(2) For urgent health care services, within forty-eight (48)
hours from submission of the request for prior authorization. No
utilization review entity may require preauthorization for an
emergency service, including post evaluation and
poststabilization services.
Section 2161.2. Preauthorization Denial Grievances.--(a) An
enrollee or the enrollee's health care provider may submit a
grievance and request an expedited review of an adverse
determination via telephone, facsimile, electronic mail or other
method. Within one (1) day of receiving an expedited request and
all information necessary to make a determination, the
utilization review entity shall provide the enrollee and the
enrollee's health care provider written confirmation of the
expedited review determination.
(b) A grievance shall be reviewed only by a physician who
satisfies any of the following conditions:
(1) Is board certified in the same specialty as a health
care practitioner who typically manages the medical condition or
disease.
(2) Is currently in active practice, provided that in events
where circumstances justify it or where the provider seeking
preauthorization specifically requests a health care provider
actively engaged in the specialty who typically manages the
medical condition or disease, the physician shall be made
available for the review.
(3) Is knowledgeable of, and has experience in, providing
the health care services under grievance.
(4) Is under contract with a utilization review entity to
perform reviews of grievances and payment of fees due under the
contract, but the performance and payment is not subject to or
contingent upon the outcome of the appeal. The following shall
apply:
(i) The physician may also be subject to a provider
agreement with the managed care plan as a network provider, but
shall not receive any other fee or compensation from the managed
care plan.
(ii) The physician's receipt of compensation from either the
managed care plan or the utilization review entity shall not be
considered by the physician in determining the conclusion
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reached by the physician.
(iii) The physician shall at all times render independent
and accurate medical judgment in reaching an opinion or
conclusion.
(iv) Failure to comply with this provision shall render the
physician subject to licensure disciplinary action by the
appropriate licensing board.
(5) Not involved in making the adverse determination.
(6) Familiar with all known clinical aspects of the health
care services under review, including all pertinent medical
records provided to the utilization review entity by the
enrollee's health care provider and any relevant record provided
to the utilization review entity by a health care facility.
(c) The utilization review entity shall ensure that
grievance review procedures satisfy the following requirements:
(1) The enrollee and the enrollee's health care provider may
challenge the adverse determination and have the right to appear
in person before the utilization review entity, including the
reviewing physician, who reviews the adverse determination.
(2) The utilization review entity shall provide the enrollee
and the enrollee's health care provider written notice of the
time and place concerning where the review meeting will take
place. Notice shall be given to the enrollee's health care
provider at least fourteen (14) days in advance of the review
meeting.
(3) If the enrollee or the enrollee's health care provider
appear in person, the utilization review entity shall offer the
enrollee or enrollee's health care provider the opportunity to
communicate with the reviewing physician, at the utilization
review entity's expense, by conference call, video conferencing
or other available technology.
(4) The physician performing the review of the grievance
shall consider all information, documentation or other material
submitted in connection with the grievance without regard to
whether the information was considered in making the adverse
determination.
(d) The following deadlines shall apply to the utilization
review entities:
(1) A utilization review entity shall decide a grievance
submitted for expedited review and notify the enrollee and the
enrollee's health care provider of the determination within two
(2) days after receiving a notice of the expedited review
request by the enrollee or the enrollee's health care provider
and all information necessary to render a decision.
(2) A utilization review entity shall issue a written
determination concerning a nonexpedited grievance not later than
thirty (30) days after receiving a notice of the grievance from
an enrollee or enrollee's health care provider.
(e) Written notice of final an adverse determination shall
be provided to the enrollee and the enrollee's health care
provider.
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(f) If the enrollee or the enrollee's health care provider
or a designee on behalf of either the enrollee or the enrollee's
health care provider has satisfied all necessary requirements
for the grievance review determination of an adverse
determination through the preauthorization process and the
determination has resulted in a continued adverse determination
either based on lack of medical necessity or an administrative
defect, the enrollee, the enrollee's health care provider or a
designee on behalf of either the enrollee or the enrollee's
health care provider or a designee may file a consumer complaint
with the Department of Health if for continued lack of medical
necessity and the Insurance Department if for administrative
defect. The complaint shall be adjudicated without unnecessary
delay in accordance with current law and a determination issued
by the relevant department with appropriate sanctions, if
applicable, under the authority given to that department.
(g) To the extent that an enrollee, an enrollee's health
care provider or a designee on behalf of either the enrollee or
the enrollee's health care provider or a designee files a
consumer complaint with either department or the Office of
Attorney General under the authority to receive the complaints,
a copy of the complaint filed with either department or the
Office of Attorney General shall be forwarded to the Insurance
Department and the copy shall serve as a new consumer complaint
to be adjudicated under the terms of this section and all other
applicable law.
Section 2195. Access Requirements in Service Areas.--If an
enrollee's safe discharge is delayed for any reason, including
lack of available posthospitalization services, including
skilled nursing facilities, home health services and postacute
rehabilitation, the managed care plan shall reimburse the
hospital for each subsequent date of service at the greater of
the contracted rate with the managed care plan for the current
level of care and service or the full diagnostic related group
payment divided by the mean length of stay for the particular
diagnostic related group.
Section 11. Nothing in this act shall be construed to
preclude an insurer from developing a program exempting a health
care provider from preauthorization protocols.
Section 12. This act shall take effect in 60 days.
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