S0225B1837A05616 MSP:EJH 09/19/22 #90 A05616
AMENDMENTS TO SENATE BILL NO. 225
Sponsor: REPRESENTATIVE PICKETT
Printer's No. 1837
Amend Bill, page 1, lines 11 through 29, by striking out "in
quality health care" in line 11 and all of lines 12 through 29
and inserting
in quality health care accountability and protection, further
providing for definitions, for responsibilities of managed
care plans, for financial incentives prohibition, for medical
gag clause prohibition, for emergency services, for
continuity of care, for procedures, for confidentiality, for
required disclosure and for internal complaint process,
providing for internal complaint process for enrollees,
further providing for appeal of complaint, for complaint
resolution, for certification and for operational standards,
providing for utilization review standards, further providing
for internal grievance process, for external grievance
process and for records, providing for adverse benefit
determinations, further providing for prompt payment of
claims, for health care provider and managed care plan
protection, for departmental powers and duties and for
penalties and sanctions, providing for regulations, further
providing for compliance with national accrediting standards
and for exceptions; making editorial changes; and making
repeals.
Amend Bill, page 2, lines 2 through 30; pages 3 through 49,
lines 1 through 30; by striking out all of said lines on said
pages and inserting
Section 1. Section 2102, Subdivision (b) heading of Article
XXI, sections 2111, 2112, 2113, 2116, 2117, 2121 and 2131,
Subdivision (f) heading of Article XXI and section 2136 of the
act of May 17, 1921 (P.L.682, No.284), known as The Insurance
Company Law of 1921, are amended to read:
Section 2102. Definitions.--As used in this article, the
following words and phrases shall have the meanings given to
them in this section:
"Active clinical practice." The practice of clinical
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medicine by a health care provider for an average of not less
than twenty (20) hours per week.
"Administrative denial." An adverse benefit determination of
prior authorization, coverage or payment based on a lack of
eligibility, failure to submit complete information or other
failure to comply with an administrative policy. The term does
not include an adverse benefit determination based on medical
necessity.
"Administrative policy." A written document or collection of
documents reflecting the terms of the contractual or operating
relationship between an insurer or MA or CHIP managed care plan
and a health care provider.
"Adverse benefit determination." An adverse benefit
determination may be any of the following:
(1) A determination by an insurer or a utilization review
entity on behalf of an insurer that, based upon the information
provided and upon application of utilization review, a request
for a benefit under a health insurance policy does not meet the
insurer's requirements for medical necessity, appropriateness,
health care setting, level of care or effectiveness or is
determined to be experimental or investigational, such that the
requested benefit is therefore denied, reduced or terminated or
payment is not provided or made, in whole or in part, for the
benefit.
(2) The denial, reduction, termination or failure to provide
or make payment, in whole or in part, for a benefit based on a
determination by an insurer of a person's eligibility for
coverage under a health insurance policy or noncompliance with
an administrative policy.
(3) A rescission of coverage determination.
"Agreement with the Department of Human Services." A
contract between an MA or CHIP managed care plan and the
Department of Human Services or primary contractor of the
Department of Human Services to manage the purchase and
provision of medical, behavioral health or home and community-
based services.
"Ancillary service plans." Any individual or group health
insurance plan, subscriber contract or certificate that provides
exclusive coverage for dental services or vision services. The
term also includes Medicare Supplement Policies subject to
section 1882 of the Social Security Act (49 Stat. 620, 42 U.S.C.
§ 1395ss) and the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) supplement.
"Applicable governmental guidelines." Clinical practice and
associated guidelines issued under the authority of the United
States Department of Health and Human Services, United States
Food and Drug Administration, Centers for Disease Control and
Prevention, Pennsylvania Department of Health or other similarly
situated Federal or State agency, department or subunit thereof
focused on the provision or regulation of medical care,
prescription drugs or public health within the United States.
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"Authorized representative." One of the following:
(1) A person, including a health care provider, to whom a
covered person or enrollee has given express written consent to
represent the covered person or enrollee in a complaint,
grievance, adverse benefit determination, internal appeal or
external review process.
(2) A person authorized by law to provide substituted
consent for a covered person or enrollee.
(3) A family member or treating health care provider
involved in providing health care to a covered person or
enrollee if the covered person or enrollee is incapacitated or
unavailable to provide consent due to a medical emergency or
necessary to prevent a serious and imminent threat to the health
or safety of the covered person or enrollee.
"Clean claim." A claim for payment for a health care service
which has no defect or impropriety. A defect or impropriety
shall include lack of required substantiating documentation or a
particular circumstance requiring special treatment which
prevents timely payment from being made on the claim. The term
shall not include a claim from a health care provider who is
under investigation for fraud or abuse regarding that claim.
"Clinical review criteria." The set of written screening
procedures, decision abstracts, clinical protocols and practice
guidelines used by an insurer or MA or CHIP managed care plan to
determine the necessity and appropriateness of health care
services.
"Closely-related service." A health care service subject to
prior authorization that is closely related in purpose,
diagnostic utility or designated health care billing code, and
provided on the same date of service as an authorized service,
such that a prudent health care provider, acting within the
scope of the provider's license and expertise, may reasonably be
expected to perform the service in conjunction with or in lieu
of the originally authorized service in response to minor
differences in observed patient characteristics or needs for
diagnostic information that were not readily identifiable until
the provider was actually performing the originally authorized
service. The term does not include an order for or
administration of a prescription drug or any part of a series or
course of treatments.
"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Complaint." A dispute or objection regarding a
participating health care provider or the coverage, operations
or management policies of [a] an insurer or MA or CHIP managed
care plan which has not been resolved by the insurer or MA or
CHIP managed care plan and has been filed with the insurer, MA
or CHIP managed care plan or [with the Department of Health or
the Insurance Department of the Commonwealth] department. The
term does not include a grievance or an adverse benefit
determination eligible for external review.
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"Concurrent [utilization] review." A review [by a
utilization review entity] performed by an insurer or MA or CHIP
managed care plan, or by a utilization review entity acting on
behalf of an insurer or MA or CHIP managed care plan of all
reasonably necessary supporting information which occurs during
an enrollee's hospital stay or course of treatment and results
in a decision to approve or deny payment for the health care
service.
"Covered benefit." A health care service as set forth in the
terms of a health insurance policy or an agreement with the
Department of Human Services. The term includes a covered
service.
"Covered person." A policyholder, subscriber or other
individual who is entitled to receive health care services under
a health insurance policy.
"Covered service." A health care service eligible for
payment under the terms of a health insurance policy or an
agreement with the Department of Human Services.
"Department." The [Department of Health] Insurance
Department of the Commonwealth.
"Discharge planning." The formal process for determining,
prior to discharge from a facility, the coordination and
management of care that a covered person or enrollee will
receive following the discharge.
"Drug formulary." A listing of health insurance policy or MA
or CHIP managed care plan preferred therapeutic drugs.
"Emergency service." [Any] A health care service provided to
[an] a covered person or enrollee 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 covered person or enrollee in
serious jeopardy 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.] The term includes emergency transportation and related
emergency services provided by a licensed ambulance service.
"Enrollee." [Any policyholder, subscriber, covered person or
other individual] An individual who is entitled to receive
health care services under [a managed care plan] an agreement
with the Department of Human Services.
"Evidence-based standard." Interventions and treatment
approaches that have been proven effective through appropriate
empirical analysis.
"Facility." A health care setting or institution providing
health care services, including:
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(1) A general, special, psychiatric or rehabilitation
hospital.
(2) An ambulatory surgical facility.
(3) A cancer treatment center.
(4) A birth center.
(5) A skilled nursing center.
(6) An inpatient, outpatient or residential drug and alcohol
treatment facility.
(7) A laboratory, imaging, diagnostic or other outpatient
medical service or testing facility.
(8) A health care provider office or clinic.
"Final adverse benefit determination." An adverse benefit
determination that has been upheld by an insurer or a
utilization review entity designated by the insurer at the
completion of the insurer's internal claim and appeal procedures
as specified in section 2161.1.
"Grievance." [As provided in subdivision (i), a] A request
to an MA or CHIP managed care plan by an enrollee or [a health
care provider, with the written consent of the enrollee,] an
enrollee's authorized representative to have [a] an MA or CHIP
managed care plan [or utilization review entity] reconsider a
decision solely concerning the medical necessity [and],
appropriateness, health care setting, level of care or
effectiveness of a health care service. If the MA or CHIP
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 or an adverse benefit
determination.
"Health care provider." A licensed hospital or health care
facility, medical equipment supplier or person who is licensed,
certified or otherwise regulated to provide health care services
under the laws of this Commonwealth, including a physician,
podiatrist, optometrist, psychologist, physical therapist,
certified nurse practitioner, registered nurse, nurse midwife,
physician's assistant, chiropractor, dentist, pharmacist or an
individual accredited or certified to provide behavioral health
services. For MA or CHIP managed care plans, the term shall also
refer to an individual providing personal assistance or
rehabilitative services.
"Health care service." Any covered treatment, admission,
procedure, 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] a
covered person or enrollee [under a managed care plan contract.]
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for the diagnosis, prevention, treatment, cure or relief of a
health condition, illness, injury, disease or functional
limitation under the terms of either a health insurance policy
or an agreement with the Department of Human Services. The term
includes home-and-community-based services provided to an
enrollee under the terms of an agreement with the Department of
Human Services.
"Health insurance policy." A policy, subscriber contract,
certificate or plan issued by an insurer that provides medical
or health care coverage. The term does not include any of the
following:
(1) An accident only policy.
(2) A credit only policy.
(3) A long-term care or disability income policy.
(4) A specified disease policy.
(5) A Medicare supplement policy.
(6) A TRICARE policy, including a Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS) supplement
policy.
(7) A fixed indemnity policy.
(8) A hospital indemnity policy.
(9) A dental only policy.
(10) A vision only policy.
(11) A workers' compensation policy.
(12) An automobile medical payment policy under 75 Pa.C.S.
(relating to vehicles).
(13) A homeowner's insurance policy.
(14) Any other similar policies providing for limited
benefits.
"Independent review organization" or "IRO." An entity
approved by the department under section 2161.10 that conducts
independent reviews of adverse benefit determinations, final
adverse benefit determinations and grievances.
"Inpatient admission." Admission to a facility for purposes
of receiving a health care service.
"Insurer." An entity licensed by the department that offers,
issues or renews an individual or group health insurance policy
that is offered or governed under any of the following:
(1) This act, including section 630 and Article XXIV.
(2) The act of December 29, 1972 (P.L.1701, No.364), known
as the "Health Maintenance Organization Act."
(3) 40 Pa.C.S. Ch. 61 (relating to health plan corporations)
or 63 (relating to professional health services plan
corporations).
The term does not include an entity operating as an MA or
CHIP managed care plan.
["Managed care plan." A health care plan that uses a
gatekeeper to manage the utilization of health care services,
integrates the financing and delivery of health care services to
enrollees by arrangements with health care providers selected to
participate on the basis of specific standards and provides
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financial incentives for enrollees to use the participating
health care providers in accordance with procedures established
by the plan. A managed care plan includes health care arranged
through an entity operating under any of the following:
(1) Section 630.
(2) The act of December 29, 1972 (P.L.1701, No.364), known
as the "Health Maintenance Organization Act."
(3) The act of December 14, 1992 (P.L.835, No.134), known as
the "Fraternal Benefit Societies Code."
(4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(5) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
The term includes an entity, including a municipality,
whether licensed or unlicensed, that contracts with or functions
as a managed care plan to provide health care services to
enrollees. The term does not include ancillary service plans or
an indemnity arrangement which is primarily fee for service.]
"Medical Assistance or Children's Health Insurance Program
managed care plan" or "MA or CHIP managed care plan." A health
care plan that uses a gatekeeper to manage the utilization of
health care services by medical assistance or children's health
insurance program enrollees and integrates the financing and
delivery of health care services to enrollees by arrangements
with health care providers selected to participate.
"Medical policy." A written document adopted, maintained and
applied by an insurer or MA or CHIP managed care plan that
combines the clinical review criteria and any additional
administrative requirements, as applicable, necessary to
articulate the insurer's or MA or CHIP managed care plan's
standards for coverage of a given health care service or set of
health care services under the terms of a health insurance
policy or an agreement with the Department of Human Services.
"Medical or scientific evidence." Evidence found in any of
the following sources:
(1) A peer-reviewed scientific study published in or
accepted for publication by a medical journal that meets
nationally recognized requirements for scientific manuscripts
and which journal submits most of its published articles for
review by experts who are not part of the journal's editorial
staff.
(2) Peer-reviewed medical literature, including literature
relating to a therapy reviewed and approved by a qualified
institutional review board, biomedical compendia and other
medical literature that meet the criteria of the National
Institutes of Health's Library of Medicine for indexing in Index
Medicus (Medline) and Elsevier Science Limited for indexing in
Excerpta Medica (EMBASE).
(3) A medical journal recognized by the Secretary of Health
and Human Services under section 1861(t)(2) of the Social
Security Act (49 Stat. 620, 42 U.S.C. § 1395x(t)(2)).
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(4) One of the following standard reference compendia:
(i) The American Hospital Formulary Service-Drug
Information.
(ii) DRUGDEX Information System.
(iii) The American Dental Association Accepted Dental
Therapeutics.
(iv) The United States Pharmacopoeia-Drug Information.
(5) Findings, studies or research conducted by or under the
auspices of a United States government agency or nationally
recognized Federal research institute, including:
(i) The United States Agency for Healthcare Research and
Quality.
(ii) The National Institutes of Health.
(iii) The National Cancer Institute.
(iv) The National Academy of Sciences.
(v) The United States Department of Health and Human
Services.
(vi) The Food and Drug Administration.
(vii) Any national board recognized by the National
Institutes of Health for the purpose of evaluating the medical
value of health care services.
(6) Other medical or scientific evidence that is comparable
to the sources specified in paragraphs (1), (2), (3), (4) and
(5).
"Medication assisted treatment." United States Food and Drug
Administration-approved prescription drugs used in combination
with counseling and behavioral health therapies and management
in the treatment of opioid use disorders.
"NAIC." The National Association of Insurance Commissioners.
"Nationally recognized medical standards." Clinical
criteria, practice guidelines and related standards established
by national quality and accreditation entities generally
recognized in the United States health care industry.
"Participating health care provider." A health care provider
that has entered into a contractual or operating relationship
with an insurer or MA or CHIP managed care plan to participate
in one or more designated networks of the insurer and to provide
health care services to covered persons or enrollees under the
terms of the insurer's administrative policy or an agreement
with the Department of Human Services.
["Plan." A managed care plan.]
"Prescription drug." A drug or biological product, as both
of those terms are defined in the act of November 24, 1976
(P.L.1163, No.259), referred to as the Generic Equivalent Drug
Law.
"Primary care provider." A health care provider who, within
the scope of the provider's practice, supervises, coordinates,
prescribes or otherwise provides or proposes to provide health
care services to [an] a covered person or enrollee, initiates
[enrollee] a referral for specialist care and maintains
continuity of [enrollee] care for the covered person or
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enrollee.
"Primary contractor." A county, consortium of counties, MA
or CHIP managed care plan or other entity that has an agreement
with the Department of Human Services to manage the purchase and
provision of behavior health services.
"Prior authorization." A prospective utilization review
performed by an insurer or MA or CHIP managed care plan, or by a
utilization review entity acting on behalf of an insurer or MA
or CHIP managed care plan, 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. The term
includes step therapy and step therapy exception requests.
"Prior authorization request." A request for prior
authorization of a health care service that meets an insurer's
or MA or CHIP managed care plan's administrative policy
requirements for such a request and includes the specific
clinical information necessary to evaluate the request under the
terms of the applicable medical policy.
["Prospective utilization review." 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.]
"Protected health information." Information or data, whether
oral or recorded in any form or medium, and personal facts or
information about events or relationships that identifies an
individual who is the subject of the information or for which
there is a reasonable basis to believe that the information
could be used to identify an individual, that relates to any of
the following:
(1) The past, present, or future physical, mental or
behavioral health or condition of an individual or a member of
the individual's family.
(2) The provision of health care services to an individual.
(3) payment for the provision of health care services to an
individual.
"Provider network." The health care providers designated by
[a] an insurer or MA or CHIP managed care plan to provide health
care services under a health insurance policy or an agreement
with the Department of Human Services.
"Provider portal." A designated section or functional
software module accessible via an insurer's or MA or CHIP
managed care plan's publicly accessible Internet website that
facilitates health care provider submission of electronic prior
authorization requests.
"Referral." A prior authorization from [a] an insurer, MA or
CHIP managed care plan or a participating health care provider
that allows [an] a covered person or enrollee to have one or
more appointments with a health care provider for a health care
service.
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"Retrospective utilization 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.] Review of medical
necessity performed by an insurer or MA or CHIP managed care
plan, or by a utilization review entity acting on behalf of an
insurer or MA or CHIP managed care plan and conducted after
health care services have been provided to a covered person or
enrollee, not including the review of a claim that is limited to
an evaluation of the reimbursement levels, veracity of
documentation, accuracy of coding or adjustment for payment.
"Service area." The geographic area for which [the] an
insurer or MA or CHIP managed care plan is licensed or has been
issued a certificate of authority.
"Specialist." A health care provider whose practice is not
limited to primary health care services and who has additional
postgraduate or specialized training, has board certification or
practices in a licensed specialized area of health care. The
term includes a health care provider who is not classified by
[a] an insurer or MA or CHIP managed care plan solely as a
primary care provider.
"Step therapy." A course of treatment in which certain
designated drugs or treatment protocols must be either
contraindicated, or used and found to be ineffective, prior to
approval of coverage of other designated drugs or treatment
protocols. The term does not include requests for coverage of
nonformulary drugs.
"Urgent health care service." A covered health care service
subject to prior authorization that is delivered on an expedited
basis for the treatment of an acute condition with symptoms of
sufficient severity pursuant to a determination by a licensed
treating physician, operating with the individual's scope of
practice and professional expertise, that the failure to provide
the service is likely to result in serious, long-term health
complications or a material deterioration in the covered
person's or enrollee's condition and prognosis.
"Urgent request." A request for prior authorization of an
urgent healthcare 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.] A set of formal
techniques designed to monitor the use of or evaluate the
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medical necessity, appropriateness, efficacy or efficiency of
health care services, procedures or settings, including prior
authorization, second opinion, certification, concurrent review,
case management, discharge planning or retrospective review, in
order to make a determination regarding coverage of the service
under the terms of a health insurance policy or an agreement
with the Department of Human Services.
"Utilization review entity." Any entity certified pursuant
to subdivision (h) that performs utilization review on behalf of
[a] an insurer or MA or CHIP managed care plan.
(b) Insurer and MA and CHIP Managed Care
Plan Requirements.
Section 2111. Responsibilities of Insurers and MA and CHIP
Managed Care Plans.--[A] An insurer or MA or CHIP managed care
plan shall do all of the following:
(1) Assure availability and accessibility of adequate health
care providers in a timely manner, which enables covered persons
or enrollees to have access to quality care and continuity of
health care services.
(2) Consult with health care providers in active clinical
practice regarding professional qualifications and necessary
specialists to be included in [the plan.] coverage under a
health insurance policy or an agreement with the Department of
Human Services.
(3) Adopt and maintain a definition of medical necessity
used by [the] an insurer or MA or CHIP managed care plan in
determining health care services.
(4) Ensure that emergency services are provided twenty-four
(24) hours a day, seven (7) days a week and provide reasonable
payment or reimbursement for emergency services.
(5) Adopt and maintain procedures by which [an] a covered
person or enrollee can obtain health care services outside the
health insurance policy's or MA or CHIP managed care plan's
service area.
(6) Adopt and maintain procedures by which [an] a covered
person or enrollee with a life-threatening, degenerative or
disabling disease or condition shall, upon request, receive an
evaluation and, if the health insurance policy's [plan's]
established standards are met or the standards established by an
agreement with the Department of Human Services, be permitted to
receive:
(i) a standing referral to a specialist with clinical
expertise in treating the disease or condition; or
(ii) the designation of a specialist to provide and
coordinate the covered person's or enrollee's primary and
specialty care.
The referral to or designation of a specialist shall be pursuant
to a treatment plan approved by the insurer or MA or CHIP
managed care plan in consultation with the primary care
provider, the covered person or enrollee and, as appropriate,
the specialist. When possible, the specialist must be a health
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care provider participating in the [plan.] health insurance
policy or MA or CHIP managed care plan's provider network.
(7) Provide direct access to obstetrical and gynecological
services by permitting [an] a covered person or enrollee to
select a health care provider participating in the [plan] health
insurance policy or MA or CHIP managed care plan's provider
network to obtain maternity and gynecological care, including
medically necessary and appropriate follow-up care and referrals
for diagnostic testing related to maternity and gynecological
care, without prior approval from a primary care provider. The
health care services shall be within the scope of practice of
the selected health care provider. The selected health care
provider shall inform the covered person's or enrollee's primary
care provider of all health care services provided.
(8) Adopt and maintain a complaint process as set forth in
subdivision (g).
(9) Adopt and maintain a grievance process as set forth in
subdivision (i).
(10) Adopt and maintain credentialing standards for health
care providers as set forth in subdivision (d).
(11) Ensure that there are participating health care
providers that are physically accessible to people with
disabilities and can communicate with individuals with sensory
disabilities in accordance with Title III of the Americans with
Disabilities Act of 1990 (Public Law 101-336, 42 U.S.C. § 12181
et seq.).
(12) Provide a list of health care providers participating
in the [plan] health insurance policy or MA or CHIP managed care
plan's provider network to the department every two (2) years or
as may otherwise be required by the department. The list shall
include the extent to which health care providers in the [plan]
health insurance policy or MA or CHIP managed care plan's
provider network are accepting new enrollees.
(13) Report to the department [and the Insurance Department]
in accordance with the requirements of this article. Such
information shall include the number, type and disposition of
all complaints [and], grievances [filed with the plan.] and
adverse benefit determinations filed with the insurer under a
health insurance policy or with the MA or CHIP managed care
plan, as applicable.
Section 2112. Financial Incentives Prohibition.--No insurer
or MA or CHIP managed care plan [shall] may use any financial
incentive that compensates a health care provider for providing
less than medically necessary and appropriate care to [an] a
covered person or enrollee. Nothing in this section shall be
deemed to prohibit [a] an insurer or MA or CHIP managed care
plan from using a capitated payment arrangement or other risk-
sharing arrangement.
Section 2113. Medical Gag Clause Prohibition.--(a) No
insurer or MA or CHIP managed care plan may penalize or restrict
a health care provider from discussing any of the following:
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(1) [the] The process that the insurer or MA or CHIP managed
care plan or any entity contracting with the insurer or MA or
CHIP managed care plan uses or proposes to use to deny payment
for a health care service[;].
(2) [medically] Medically necessary and appropriate care
with or on behalf of [an] a covered person or enrollee,
including information regarding the nature of treatment; risks
of treatment; alternative treatments; or the availability of
alternate therapies, consultation or tests[; or].
(3) [the] The decision of [any] an insurer or MA or CHIP
managed care plan to deny payment for a health care service.
(b) A provision to prohibit or restrict disclosure of
medically necessary and appropriate health care information
contained in a contract with a health care provider is contrary
to public policy and shall be void and unenforceable.
(c) No insurer or MA or CHIP managed care plan [shall] may
terminate the employment of or a contract with a health care
provider for any of the following:
(1) Advocating for medically necessary and appropriate
health care consistent with the degree of learning and skill
ordinarily possessed by a reputable health care provider
practicing according to the applicable legal standard of care.
(2) Filing a complaint, grievance or external review
pursuant to the procedures set forth in this article.
(3) Protesting a decision, policy or practice that the
health care provider, consistent with the degree of learning and
skill ordinarily possessed by a reputable health care provider
practicing according to the applicable legal standard of care,
reasonably believes interferes with the health care provider's
ability to provide medically necessary and appropriate health
care.
(d) Nothing in this section shall:
(1) Prohibit [a] an insurer or MA or CHIP managed care plan
from making a determination not to pay for a particular medical
treatment, supply or service, enforcing reasonable peer review
or utilization review protocols or making a determination that a
health care provider has or has not complied with appropriate
protocols.
(2) Be construed as requiring [a] an insurer or MA or CHIP
managed care plan to provide, reimburse for or cover counseling,
referral or other health care services if the insurer or MA or
CHIP managed care plan:
(i) objects to the provision of that service on moral or
religious grounds; and
(ii) makes available information on its policies regarding
such health care services to covered person or enrollees and
prospective covered person or enrollees.
Section 2116. Emergency Services.--(a) If [an] a covered
person or enrollee seeks emergency services and the emergency
health care provider determines that emergency services are
necessary, the emergency health care provider shall initiate
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necessary intervention to evaluate and, if necessary, stabilize
the condition of the covered person or enrollee without seeking
or receiving authorization from the insurer or MA or CHIP
managed care plan. The insurer or MA or CHIP managed care plan
may not require a health care provider to submit a request for
prior authorization for an emergency service. The insurer or MA
or CHIP managed care plan shall pay all reasonably necessary
costs associated with emergency services provided during the
period of emergency, subject to all copayments, coinsurances or
deductibles. When processing a reimbursement claim for emergency
services, [a] an insurer or MA or CHIP managed care plan shall
consider both the presenting symptoms and the services provided.
(a.1) The emergency health care provider shall notify the
covered person's insurer or enrollee's MA or CHIP managed care
plan of the provision of emergency services and the condition of
the covered person or enrollee.
(1) The health care provider shall notify a covered person's
insurer of the provision of emergency services and the condition
of the covered person within two business days following the
period of emergency.
(2) The health care provider shall notify the enrollee's MA
or CHIP managed care plan of the provision of emergency services
and the condition of the enrollee within ten days following the
period of emergency.
(a.2) If [an] a covered person's or enrollee's condition has
stabilized and the covered person or enrollee can be transported
without suffering detrimental consequences or aggravating the
covered person's or enrollee's condition, the covered person or
enrollee may be relocated to another facility to receive
continued care and treatment as necessary.
(b) For emergency services rendered by a licensed emergency
medical services agency, as defined in 35 Pa.C.S. § 8103
(relating to definitions), that has the ability to transport
patients or is providing and billing for emergency services
under an agreement with an emergency medical services agency
that has that ability, the insurer or MA or CHIP managed care
plan may not deny a claim for payment solely because the
enrollee did not require transport or refused to be transported.
(c) For emergency services provided to [medical assistance
participants] MA or CHIP managed care plan enrollees, the
following provisions shall apply:
(1) The provisions of subsection (b) shall apply to the same
services provided to medical assistance participants under
Article IV of the act of June 13, 1967 (P.L.31, No.21), known as
the Human Services Code.
(2) Payment for the services shall be in accordance with the
current MA or CHIP managed care contracted rates.
(3) Sufficient funds shall be appropriated each fiscal year
for payment of the services.
[(d) The provisions of subsection (b) shall apply to all
group and individual major medical health insurance policies
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issued by a licensed health insurer.]
Section 2117. Continuity of Care.--(a) Except as provided
under subsection (b), if [a] an insurer or MA or CHIP managed
care plan initiates termination of its contract with a
participating health care provider, [an] a covered person or
enrollee may continue an ongoing course of treatment with that
health care provider at the covered person's or enrollee's
option for a transitional period of up to sixty (60) days from
the date the covered person or enrollee was notified by the
insurer or MA or CHIP managed care plan of the termination or
pending termination. The insurer or MA or CHIP managed care
plan, in consultation with the covered person or enrollee and
the health care provider, may extend the transitional period if
determined to be clinically appropriate. In the case of [an] a
covered person or enrollee in the second or third trimester of
pregnancy at the time of notice of the termination or pending
termination, the transitional period shall extend through
postpartum care related to the delivery. Any health care service
provided under this section shall be covered by the insurer or
MA or CHIP managed care plan under the same terms and conditions
as applicable for participating health care providers.
(b) If [the] an insurer or MA or CHIP managed care plan
terminates the contract of a participating health care provider
for cause, including breach of contract, fraud, criminal
activity or posing a danger to [an] a covered person or enrollee
or the health, safety or welfare of the public as determined by
the insurer or MA or CHIP managed care plan, the insurer or MA
or CHIP managed care plan shall not be responsible for health
care services provided to the covered person or enrollee
following the date of termination.
(c) If [the] an insurer or MA or CHIP managed care plan
terminates the contract of a participating primary care
provider, the insurer or MA or CHIP managed care plan shall
notify every covered person or enrollee served by that provider
of the insurer's or MA or CHIP managed care plan's termination
of its contract and shall request that the covered person or
enrollee select another primary care provider.
(d) A new covered person or enrollee may continue an ongoing
course of treatment with a nonparticipating health care provider
for a transitional period of up to sixty (60) days from the
effective date of enrollment in a health insurance policy or MA
or CHIP managed care plan. The insurer or MA or CHIP managed
care plan, in consultation with the covered person or enrollee
and the health care provider, may extend this transitional
period if determined to be clinically appropriate. In the case
of a new covered person or enrollee in the second or third
trimester of pregnancy on the effective date of enrollment, the
transitional period shall extend through postpartum care related
to the delivery. Any health care service provided under this
section shall be covered by the health insurance policy or MA or
CHIP managed care plan under the same terms and conditions as
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applicable for participating health care providers.
(e) [A] An insurer or MA or CHIP managed care plan may
require a nonparticipating health care provider whose health
care services are covered under this section to meet the same
terms and conditions as a participating health care provider.
(f) Nothing in this section shall require [a] an insurer or
MA or CHIP managed care plan to provide health care services
that are not otherwise covered under the terms and conditions of
the [plan] covered person's health insurance policy or an
agreement with the Department of Human Services.
Section 2121. Credentialing Procedures.--(a) [A] An insurer
or MA or CHIP managed care plan shall establish a credentialing
process to enroll qualified health care providers and create an
adequate provider network. [The process shall be approved by the
department and shall include written criteria and procedures for
initial enrollment, renewal, restrictions and termination of
credentials for health care providers.]
(a.1) An insurer's or MA or CHIP managed care plan's
credentialing process shall be subject to approval by the
department and shall include written criteria and procedures for
at least the following:
(1) Initial credentialing.
(2) Renewal of credentialing.
(3) Restricting and terminating the credentials for health
care providers.
(b) The department shall establish credentialing standards
for insurers and MA or CHIP managed care plans. The department
may adopt nationally recognized accrediting standards to
establish the credentialing standards for insurers and MA or
CHIP managed care plans.
(c) [A] An insurer or MA or CHIP managed care plan shall
submit a report to the department regarding its credentialing
process at least every two (2) years or as may otherwise be
required by the department.
(d) [A] An insurer or MA or CHIP managed care plan shall
disclose relevant credentialing criteria and procedures to
health care providers that apply to participate or that are
participating in the insurer's or managed care plan's provider
network. [A] An insurer or MA or CHIP managed care plan shall
also disclose relevant credentialing criteria and procedures
pursuant to a court order or rule. Any individual providing
information during the credentialing process of [a] an insurer
or MA or CHIP managed care plan shall have the protections set
forth in the act of July 20, 1974 (P.L.564, No.193), known as
the "Peer Review Protection Act."
(e) No insurer or MA or CHIP managed care plan [shall] may
exclude or terminate a health care provider from participation
in the [plan] insurer's or MA or CHIP managed care plan's
provider network due to any of the following:
(1) The health care provider engaged in any of the
activities set forth in section 2113(c).
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(2) The health care provider has a practice that includes a
substantial number of patients with expensive medical
conditions.
(3) The health care provider objects to the provision of or
refuses to provide a health care service on moral or religious
grounds.
(f) If [a] an insurer or MA or CHIP managed care plan denies
enrollment or renewal of credentials to a health care provider,
the insurer or MA or CHIP managed care plan shall provide the
health care provider with written notice of the decision. The
notice shall include a clear rationale for the decision.
Section 2131. Confidentiality.--(a) [A] An insurer or MA or
CHIP managed care plan [and a utilization review entity] shall
adopt and maintain procedures to ensure that all [identifiable]
protected health information regarding covered person or
enrollee health, diagnosis and treatment is adequately protected
and remains confidential in compliance with all applicable
Federal and State laws and regulations and professional ethical
standards.
(b) To the extent [a] an insurer or MA or CHIP managed care
plan maintains medical records, the insurer or MA or CHIP
managed care plan shall adopt and maintain procedures to ensure
that covered persons and enrollees have timely access to their
medical records, including medical records provided by a health
care provider in the context of utilization review or a
complaint, grievance or adverse benefit determination, unless
prohibited by Federal or State law or regulation.
(c) (1) Information regarding [an] a covered person's or
enrollee's health or treatment shall be available to the covered
person or enrollee, the covered person's or enrollee's
[designee] authorized representative or as necessary to prevent
death or serious injury.
(2) Nothing in this section shall:
(i) Prevent disclosure necessary to determine coverage,
review complaints [or], grievances or adverse benefit
determinations, conduct utilization review or facilitate payment
of a claim.
(ii) Deny the department[, the Insurance Department] or the
Department of [Public Welfare] Human Services access to records
for purposes of quality assurance, investigation of complaints
[or], grievances or adverse benefit determinations, enforcement
or other activities related to compliance with this article and
other laws of this Commonwealth. Records shall be accessible
only to department employes or agents with direct
responsibilities under the provisions of this subparagraph.
(iii) Deny access to information necessary for a utilization
review entity to conduct a review under this article.
(iv) Deny access to the insurer or MA or CHIP managed care
plan for internal quality review, including reviews conducted as
part of the insurer's or MA or CHIP managed care plan's quality
oversight process. During such reviews, covered persons and
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enrollees shall remain anonymous to the greatest extent
possible.
(v) Deny access to insurers or MA or CHIP managed care
plans, health care providers and their respective designees for
the purpose of providing patient care management, outcomes
improvement and research. For this purpose, covered persons and
enrollees shall provide consent and shall remain anonymous to
the greatest extent possible.
(f) Information for Covered
Persons and Enrollees.
Section 2136. Required Disclosure.--(a) [A] An insurer or
MA or CHIP managed care plan shall supply each covered person or
enrollee and, upon written request, each prospective covered
person or enrollee or health care provider with the following
written information. Such information shall be easily
understandable by the layperson and shall include, but not be
limited to:
(1) A description of coverage, benefits and benefit
maximums, including benefit limitations and exclusions of
coverage, health care services and the definition of medical
necessity used by the insurer or MA or CHIP managed care plan in
determining whether these benefits will be covered. The
following statement or substantially similar statement shall be
included in all marketing materials in boldface type:
For Insurers: This [managed care plan] health insurance
policy may not cover all your health care expenses. Read your
contract or member handbook carefully to determine which
health care services are covered.
For MA or CHIP managed care plans: Your managed care plan may
not cover all your health care expenses. Read your member
handbook carefully to determine which health care services
are covered.
The notice shall be followed by a telephone number to contact
the insurer or MA or CHIP managed care plan.
(2) A description of all necessary prior authorizations or
other requirements for nonemergency health care services as
required by section 2155.
(3) An explanation of [an] a covered person's or enrollee's
financial responsibility for payment of premiums, coinsurance,
copayments, deductibles and other charges, annual limits on [an]
a covered person's or enrollee's financial responsibility and
caps on payments for health care services provided under the
[plan] health insurance policy or an agreement with the
Department of Human Services.
(4) An explanation of [an] a covered person's or enrollee's
financial responsibility for payment when a health care service
is provided by a nonparticipating health care provider, when a
health care service is provided by any health care provider
without required authorization or when the care rendered is not
covered [by the plan] under the health insurance policy or by an
agreement with the Department of Human Services.
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(5) A description of how the insurer or MA or CHIP managed
care plan addresses the needs of non-English-speaking covered
persons or enrollees.
(6) A notice of mailing addresses and telephone numbers
necessary to enable [an] a covered person or enrollee to obtain
approval or authorization of a health care service or other
information regarding the health insurance policy or services
covered by the MA or CHIP managed care plan.
(7) A summary of the insurer's or MA or CHIP managed care
plan's utilization review policies and procedures.
(8) A summary of all complaint [and], grievance or adverse
benefit determination procedures used to resolve disputes
between the insurer or MA or CHIP managed care plan and [an] a
covered person or enrollee or a health care provider, including:
(i) The procedure to file a complaint [or], grievance or
adverse benefit determination appeal as set forth in this
article, including a toll-free telephone number to obtain
information regarding the filing and status of a complaint [or],
grievance or adverse benefit determination.
(ii) The right to appeal a decision relating to a complaint
[or], grievance or adverse benefit determination.
(iii) The covered person's or enrollee's right to designate
a representative to participate in the complaint [or], grievance
or adverse benefit determination process as set forth in this
article.
(iv) A notice that all [disputes] decisions involving denial
of payment for a health care service will be made by qualified
personnel with experience in the same or similar scope of
practice and that all notices of decisions will include
information regarding the basis for the determination.
(9) A description of the procedure for providing emergency
services twenty-four (24) hours a day. The description shall
include:
(i) A definition of emergency services as set forth in this
article.
(ii) Notice that emergency services are not subject to prior
approval.
(iii) The covered person's or enrollee's financial and other
responsibilities regarding emergency services, including the
receipt of these services outside the insurer's or MA or CHIP
managed care plan's service area.
(10) A description of the procedures for covered persons or
enrollees to select a participating health care provider,
including how to determine whether a participating health care
provider is accepting new [enrollees] patients.
(11) A description of the procedures for changing primary
care providers and specialists.
(12) A description of the procedures by which [an] a covered
person or enrollee may obtain a referral to a health care
provider outside the health insurance policy's or MA or CHIP
managed care plan's provider network when that provider network
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does not include a health care provider with appropriate
training and experience to meet the health care service needs of
[an] a covered person or enrollee.
(13) A description of the procedures that [an] a covered
person or enrollee with a life-threatening, degenerative or
disabling disease or condition shall follow and satisfy to be
eligible for either of the following:
(i) [a] A standing referral to a specialist with clinical
expertise in treating the disease or condition[; or].
(ii) [the] The designation of a specialist to provide and
coordinate the covered person's or enrollee's primary and
specialty care.
(14) A list by specialty of the name, address and telephone
number of all [participating] health care providers
participating in the provider network for the health insurance
policy or MA or CHIP managed care plan. The list may be a
separate document and shall be updated at least [annually.] once
every 90 days or more frequently as may be required by Federal
or State law, including section 2799A-5 of the Public Health
Service Act (58 Stat. 682, 42 U.S.C. § 201 et seq.)
(15) A list of the information available to covered persons
or enrollees or prospective covered persons or enrollees, upon
written request, under subsection (b).
(b) Each insurer or MA or CHIP managed care plan shall, upon
written request of [an] a covered person or enrollee or
prospective covered person or enrollee, provide the following
written information:
(1) A list of the names, business addresses and official
positions of the membership of the board of directors or
officers of the insurer or MA or CHIP managed care plan.
(2) The procedures adopted to protect the confidentiality of
medical records and other covered person or enrollee
information.
(3) A description of the credentialing process for health
care providers.
(4) A list of the participating health care providers
affiliated with participating hospitals.
(5) Whether a specifically identified drug is included or
excluded from coverage.
(6) A description of the process by which a health care
provider can prescribe specific drugs, drugs used for an off-
label purpose, biologicals and medications not included in the
drug formulary for prescription drugs [or biologicals] when the
formulary's equivalent has been ineffective in the treatment of
the covered person's or enrollee's disease or if the drug causes
or is reasonably expected to cause adverse or harmful reactions
to the covered person or enrollee.
(7) A description of the procedures followed by the insurer
or MA or CHIP managed care plan to make decisions about the
experimental nature of individual drugs, medical devices or
treatments.
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(8) A summary of the methodologies used by the insurer or MA
or CHIP managed care plan to reimburse for health care services.
Nothing in this paragraph shall be construed to require
disclosure of individual contracts or the specific details of
any financial arrangement between [a] an insurer or MA or CHIP
managed care plan and a health care provider.
(9) A description of the procedures used in the insurer's or
MA or CHIP managed care plan's quality assurance program.
(10) Other information as may be required by the department
or the Insurance Department.
(c) (1) An insurer shall include a description of the
insurer's external review procedures in or attached to the
policy, certificate, membership booklet, outline of coverage or
other evidence of coverage the insurer provides to covered
persons, including whether the insurer has complied with the
surprise billing and cost-sharing protections under the No
Surprises Act (Pub. L. 116-260, Div. BB, Title I, 134 Stat.
2758).
(2) The disclosure required by paragraph (1) shall be in a
format as prescribed by the department.
(3) The description of procedures required under subsection
(a) shall include:
(i) A statement that informs the covered person of the right
to file a request for external review of an adverse benefit
determination or final adverse benefit determination, including
whether the insurer has complied with the surprise billing and
cost sharing protections under the No Surprise Act.
(ii) The telephone number and address of the department.
(iii) A statement that, when filing a request for an
external review, the covered person is required to authorize the
release of medical records of the covered person that may be
required to be reviewed for the purpose of reaching a decision
on the external review.
(iv) An explanation that external review is available when
the adverse benefit determination or final adverse benefit
determination involves an issue of medical necessity,
appropriateness, health care setting, level of care or
effectiveness.
Section 2. Section 2141 of the act is amended to read:
Section 2141. Internal Complaint Process for Covered
Persons.--(a) [A managed care plan] An insurer shall establish
and maintain an internal complaint process with two levels of
review by which [an enrollee] a covered person or the covered
person's authorized representative shall be able to file a
complaint [regarding a participating health care provider or the
coverage, operations or management policies of the managed care
plan].
(b) The complaint process shall consist of an initial review
to include all of the following:
(1) A review by an initial review committee consisting of
one or more employes of the [managed care plan] insurer.
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(2) The allowance of a written or oral complaint.
(3) The allowance of written data or other information.
(4) A review or investigation of the complaint which shall
be completed within thirty (30) days of receipt of the
complaint.
(5) A written notification to the [enrollee] covered person
regarding the decision of the initial review committee within
five (5) business days of the decision. Notice shall include the
basis for the decision and the procedure to file a request for a
second level review of the decision of the initial review
committee.
(c) The complaint process shall include a second level
review that includes all of the following:
(1) A review of the decision of the initial review committee
by a second level review committee consisting of three or more
individuals who did not participate in the initial review. At
least one third of the second level review committee shall not
be employed by the [managed care plan] insurer.
(2) A written notification to the [enrollee] covered person
of the right to appear before the second level review committee.
(3) A requirement that the second level review be completed
within forty-five (45) days of receipt of a request for such
review.
(4) A written notification to the [enrollee] covered person
regarding the decision of the second level review committee
within five (5) business days of the decision. The notice shall
include the basis for the decision and the procedure for
appealing the decision to the department [or the Insurance
Department].
Section 3. The act is amended by adding a section to read:
Section 2141.1. Internal Complaint Process for Enrollees.--
(a) An MA or CHIP managed care plan shall establish and
maintain an internal complaint process by which an enrollee or
the enrollee's authorized representative shall be able to file a
complaint.
(b) The complaint process shall consist of a review to
include all of the following:
(1) A review by a review committee consisting of one or more
employes of the MA or CHIP managed care plan.
(2) The allowance of a written or oral complaint.
(3) The allowance of written data or other information.
(4) Written notification to the enrollee of the decision of
the review committee within thirty (30) days of receipt of the
complaint, unless the time frame for deciding the complaint has
been extended by up to fourteen (14) days at the request of the
enrollee.
(5) The written notification of the decision shall include
the basis for the decision and the procedure to file a request
for a second level review of the decision of the review
committee, except as provided in paragraph (6).
(6) The written notification of the decision shall include
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the basis for the decision and the procedure to file an appeal
of a complaint if the complaint is about one of the following:
(i) A denial because the service or item is not a covered
service.
(ii) The failure of the MA or CHIP managed care plan to meet
the required time frames for providing a service or item in a
timely manner.
(iii) The failure of the MA or CHIP managed care plan to
decide a complaint or grievance within the required time frames.
(iv) A denial of payment by the MA or CHIP managed care plan
after the service or item has been delivered because the service
or item was provided by a health care provider not enrolled in
the medical assistance program.
(v) A denial of payment by the MA or CHIP managed care plan
after the service or item has been delivered because the service
or item provided is not a covered service or item for the
enrollee.
(vi) A denial of an enrollee's request to dispute a
financial liability.
(c) For all complaints except complaints listed in
subsection (b)(6), the complaint process shall include a second
level review that includes all of the following:
(1) A review of the decision of the review committee by a
second level review committee consisting of three or more
individuals who did not participate in the initial review. At
least one-third of the second level review committee shall not
be employed by the MA or CHIP managed care plan.
(2) A written notification to the enrollee of the right to
appear before the second level review committee.
(3) A written notification to the enrollee of the decision
of the second level review committee within forty-five (45) days
of receipt of the second level complaint, which shall include
the basis for the decision and the procedure for appealing the
decision to the department.
Section 4. Sections 2142 and 2143, Subdivision (h) heading
of Article XXI and sections 2151 and 2152 of the act are amended
to read:
Section 2142. Appeal of Complaint or Administrative Adverse
Benefit Determination.--[(a) An enrollee shall have fifteen
(15) days from receipt of the notice of the decision from the
second level review committee to appeal the decision to the
department or the Insurance Department, as appropriate.
(b) All records from the initial review and second level
review shall be transmitted to the appropriate department in the
manner prescribed. The enrollee, the health care provider or the
managed care plan may submit additional materials related to the
complaint.]
(a) The following shall apply:
(1) A covered person may appeal a decision about the
coverage, operations or management policies of an insurer, other
than decisions that are adverse benefit determinations.
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(2) An enrollee or the enrollee's authorized representative
shall have fifteen (15) days from receipt of the notice of
decision to appeal the decision to the department if the subject
of the complaint is listed in section 2141.1(b)(6).
(3) A covered person or enrollee, or covered person's or
enrollee's authorized representative, shall have fifteen (15)
days from receipt of the notice of the decision from the second
level review committee to appeal the decision to the department.
(4) All records from the review shall be transmitted to the
department in the manner prescribed. The covered person,
enrollee, health care provider or insurer or MA or CHIP managed
care plan may submit additional materials related to the
complaint.
(b) (1) A covered person shall have fifteen (15) days from
receipt of the notice of a decision on an administrative adverse
benefit determination conducted under section 2161.1 to appeal
the decision to the department.
(2) All records from the internal claim and appeal procedure
shall be transmitted to the department in the manner prescribed.
The covered person, health care provider or insurer may submit
additional materials related to the administrative adverse
benefit determination.
(c) The covered person or enrollee may be represented by an
attorney or other individual before the appropriate department.
(d) The [appropriate] department shall determine whether a
violation of this article has occurred and may impose any
penalties authorized by this article.
Section 2143. Complaint or Administrative Adverse Benefit
Determination Resolution.--Nothing in this subdivision shall
prevent the department [or the Insurance Department] from
communicating with the covered person or enrollee[,] or the
health care provider [or the], insurer or MA or CHIP managed
care plan as appropriate to assist in the resolution of a
complaint or administrative adverse benefit determination. Such
communication may occur at any time during the [complaint]
process.
(h) Utilization Review Entity Standards.
Section 2151. Certification.--(a) A utilization review
entity may not review health care services delivered or proposed
to be delivered in this Commonwealth unless the entity is
certified by the department to perform utilization review. [A
utilization review entity operating in this Commonwealth on or
before the effective date of this article shall have one year
from the effective date of this article to apply for
certification.]
(b) The department [shall] may grant certification to a
utilization review entity that meets the requirements of this
section. Certification shall be renewed every three years unless
otherwise subject to additional review, suspension or revocation
by the department.
(c) The department may adopt a nationally recognized
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accrediting body's standards to certify utilization review
entities to the extent the standards meet or exceed the
standards set forth in this article.
(d) The department may prescribe application and renewal
fees for certification. The fees shall reflect the
administrative costs of certification [and shall be deposited in
the General Fund].
(e) [A licensed insurer or a] An insurer or MA or CHIP
managed care plan with a certificate of authority shall comply
with the standards and procedures of this subdivision but shall
not be required to obtain separate certification as a
utilization review entity.
Section 2152. Operational Standards.--(a) A utilization
review entity shall do all of the following:
(1) Respond to inquiries relating to utilization review
determinations by:
(i) providing toll-free telephone access at least forty (40)
hours per week during normal business hours;
(ii) maintaining a telephone answering service or recording
system during nonbusiness hours; and
(iii) responding to each telephone call received by the
answering service or recording system regarding a utilization
review determination within one (1) business day of the receipt
of the call.
(2) Protect the confidentiality of covered person or
enrollee medical records as set forth in section 2131.
(3) Ensure that a health care provider is able to verify
that an individual requesting information on behalf of the
insurer or MA or CHIP managed care plan is [a legitimate] an
authorized representative of the insurer or MA or CHIP managed
care plan.
(4) Conduct utilization reviews based on the medical
necessity [and], appropriateness, health care setting, level of
care or effectiveness of the health care service being reviewed
[and provide notification within the following time frames:].
(4.1) If performing a utilization review for a request for
health care services for an covered person or enrollee of an
insurer or MA or CHIP managed care plan, provide notification
within the following time frames:
(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] the time frame specified in section 2155.
(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.
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(5) Ensure that personnel conducting a utilization review
have current licenses in good standing or other required
credentials, without restrictions, from the appropriate agency.
(6) Provide all decisions in writing to include the basis
and clinical rationale for the decision.
(7) Notify the health care provider of additional facts or
documents required to complete the utilization review within
[forty-eight (48) hours of receipt of the request for review]
the time frames specified in section 2155.
(8) Maintain a written record of utilization review
decisions adverse to covered persons or enrollees for not less
than three (3) years, including a detailed justification and all
required notifications to the health care provider and the
covered person or enrollee.
(b) Compensation to any person or entity performing
utilization review may not contain incentives, direct or
indirect, for the person or entity to approve or deny payment
for the delivery of any health care service.
(c) Utilization review that results in a denial of payment
for a health care service shall be made by a licensed physician
that meets the qualifications in section 2155(c), except as
provided in [subsection (d)] subsections (d) and (e).
(d) A licensed psychologist may perform a utilization review
for behavioral health care services within the psychologist's
scope of practice if the psychologist's clinical experience
provides sufficient experience to review that specific
behavioral health care service. The use of a licensed
psychologist to perform a utilization review of a behavioral
health care service shall be approved by the department as part
of the certification process under section 2151. A licensed
psychologist shall not review the denial of payment for a health
care service involving inpatient care or a prescription drug.
(e) A licensed dentist may perform a utilization review for
dental services within the dentist's scope of practice if the
dentist's clinical experience provides sufficient experience to
review that specific dental service. The use of a licensed
dentist to perform a utilization review of a dental service
shall be approved by the department as part of the certification
process under section 2151.
Section 5. Article XXI of the act is amended by adding a
subdivision to read:
(h.1) Utilization Review Standards.
Section 2153. Provider portal.
(a) Establishment of provider portal.--Within 18 months
following the effective date of this section, an insurer or MA
or CHIP managed care plan shall establish a provider portal that
includes, at minimum, the following features:
(1) Electronic submission of prior authorization
requests.
(2) Access to the insurer's or MA or CHIP managed care
plan's applicable medical policies.
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(3) Information necessary to request a peer-to-peer
review.
(4) Contact information for the insurer's or MA or CHIP
managed care plan's relevant clinical or administrative
staff.
(5) For prior authorization service not subject to
electronic submission via the provider portal, copies of
applicable submission forms.
(6) Instructions for the submission of prior
authorization requests if the insurer's or MA or CHIP managed
care plan's provider portal is unavailable for any reason.
(b) Training and support for portal use.--Within six months
following the establishment of a provider portal under
subsection (a), an insurer or MA or CHIP managed care plan shall
make available to health care providers and their affiliated or
employed staff access to training on the use of the insurer's or
MA or CHIP managed care plan's provider portal.
(c) Required use of provider portal.--
(1) Within 18 months following the establishment of a
provider portal under subsection (a), a health care provider
seeking prior authorization shall submit the request via an
insurer's or MA or CHIP managed care plan's provider portal
unless an exception applies.
(2) An insurer or MA or CHIP managed care plan may
require a health care provider to submit a prior
authorization request through the provider portal unless any
of the following exceptions applies:
(i) The portal is not available and operational at
the time of attempted submission.
(ii) The health care provider does not have access
to the insurer's or MA or CHIP managed care plan's
operational provider portal.
(iii) The health care provider satisfies an
allowance by the insurer or MA or CHIP managed care plan
for submission other than through the provider portal.
Section 2154. Medical policies and clinical review criteria.
(a) Medical policies.--
(1) An insurer or MA or CHIP managed care plan shall
make available its current medical policies through the
insurer's or MA or CHIP managed care plan's publicly
accessible Internet website and provider portal.
(2) Each medical policy developed by an insurer or MA or
CHIP managed care plan shall identify the clinical review
criteria used in the policy's development. The insurer or MA
or CHIP managed care plan shall identify any third-party
licensure restrictions preventing disclosure of all or part
of clinical review criteria.
(3) An insurer or MA or CHIP managed care plan shall
review each adopted medical policy on at least an annual
basis.
(4) (i) An insurer or MA or CHIP managed care plan
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shall notify providers of a change to a medical policy as
follows:
(A) In the case of policy change due to a change
in Federal or State law or binding agency guidance,
when the required implementation date of that policy
change is sooner than 30 days, as soon as
practicable.
(B) In the case of a change to a medical policy
that modifies, eliminates or suspends either clinical
or administrative criteria and that directly results
in less restrictive coverage of a given service,
within 30 days after application of the change.
(C) In cases other than in clauses (A) and (B),
at least 30 days prior to application of the change.
(ii) A change notification may be provided through
reasonable means, including posting of an updated and
dated medical policy reflecting the change.
(b) Clinical review criteria.--
(1) Clinical review criteria adopted by an insurer or MA
or CHIP managed care plan at the time of medical policy
development or review shall:
(i) Be based on applicable nationally recognized
medical standards.
(ii) Be consistent with applicable governmental
guidelines.
(iii) Provide for the delivery of a health care
service in a clinically appropriate type, frequency and
setting and for a clinically appropriate duration.
(iv) Reflect the current medical and scientific
evidence regarding emerging procedures, clinical
guidelines and best practices as articulated in
independent, peer-reviewed medical literature.
(2) Nothing in this section shall require an insurer or
MA or CHIP managed care plan to provide coverage for a health
care service to a covered person or enrollee that is
otherwise excluded from coverage under a health insurance
policy or an agreement with the Department of Human Services.
Section 2155. Prior authorization review.
(a) General rule.--
(1) An insurer or MA or CHIP managed care plan shall
make a determination relating to prior authorization based on
the insurer's or MA or CHIP managed care plan's review of a
prior authorization request and the following:
(i) The insurer's or MA or CHIP managed care plan's
medical policy.
(ii) The insurer's or MA or CHIP managed care plan's
administrative policy.
(iii) All medical information related to the
enrollee or covered person.
(iv) Any medical or scientific evidence submitted by
the requesting provider.
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(2) At the time of review, an insurer or MA or CHIP
managed care plan shall verify the covered person's or
enrollee's eligibility for coverage under the terms of the
applicable health insurance policy or an agreement with the
Department of Human Services.
(3) Appeals of administrative adverse benefit
determinations shall be subject to the complaint process in
section 2142.
(b) List of services subject to review.--An insurer or MA or
CHIP managed care plan shall make available a list, posted in a
publicly accessible format a