[31 Pa.B. 3043]
[Continued from previous Web Page]
OPERATIONAL STANDARDS § 9.751. UR system description.
(a) An entity performing UR shall have a written UR system description which shall include the following:
(1) The scope of the program.
(2) The process used in making decisions.
(3) The resources used in making decisions.
(4) The requirements of this section and of §§ 9.752 and 9.753 (relating to UR system standards; and time frames for UR).
(b) The entity shall evaluate its UR system annually. The evaluation shall include a report to the board of directors or the quality assurance or quality improvement committee, and shall address the following:
(1) The appropriateness of clinical criteria.
(2) The consistency of decisionmaking through the conduct of reliability studies of staff application of utilization criteria.
(3) Staff resources and training.
(4) The timeliness of decisions.
(c) The UR system shall include a policy and procedure to enable a health care provider to verify that an individual requesting information for UR purposes is a legitimate representative of the entity.
(d) The entity shall ensure that it has sufficient staff, resources and program oversight to ensure adherence to this subchapter, and to section 2152 of the act (40 P. S. § 991.2152).
(e) The entity shall make this description available to the Department for review every 3 years or upon request for the conduct of any investigation necessary to determine compliance of the entity with Act 68 and applicable sections of this chapter.
§ 9.752. UR system standards.
(a) An entity performing UR shall include a physician in any UR program.
(b) An entity performing UR shall develop clinical criteria to be used in making review decisions as follows:
(1) The clinical criteria shall be developed with input from health care providers in active clinical practice.
(2) The clinical criteria shall be reviewed regularly by the entity performing UR and shall be modified to reflect current medical standards.
(3) The entity shall make its UR criteria available upon the written request of any health care provider.
(c) A UR decision denying or approving payment of a service shall be based on the medical necessity and appropriateness of the requested service, the enrollee's individual circumstances, and the applicable contract language concerning benefits and exclusions. UR criteria may not be the sole basis for the decision.
(d) A UR decision denying payment based on medical necessity and appropriateness shall be made by a licensed physician. An approved licensed psychologist may perform UR for a behavioral health care service within the psychologist's scope of practice if the psychologist's clinical experience provides sufficient expertise to review that specific behavioral health care service, and the following standards are satisfied:
(1) An approved licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug.
(2) The use of a licensed psychologist to perform UR must be approved by the Department as part of the certification process for CREs.
(e) An entity performing UR shall notify the health care provider within 48 hours of the request for service of additional facts, documents or information required to complete the UR.
(f) If a UR decision includes a denial, it shall include the contractual basis and clinical reasons for the denial. If a UR decision is a denial, or approves anything less than what was requested, it shall include language informing the enrollee of how to appeal the decision, including location to which the appeal must be sent and time frames.
(g) Copies of written decisions of internal grievance reviews conducted by CREs shall be sent to the plan at the same time the letter is sent to the enrollee, the enrollee's representative, and to the health care provider if the provider filed the grievance with the consent of the enrollee.
§ 9.753. Time frames for UR.
(a) A concurrent UR decision shall be communicated to the plan, the enrollee and the health care provider within 1-business day of the receipt of all supporting information reasonably necessary to complete the review. The plan shall give the enrollee and the health care provider written or electronic confirmation of the decision within 1-business day of communicating the decision.
(b) A prospective UR decision shall be communicated to the plan, enrollee and health care provider within 2-business days of the receipt of all supporting information reasonably necessary to complete the review. The plan shall give the enrollee and the health care provider written or electronic confirmation of the decision within 2-business days of communicating the decision.
(c) A retrospective UR decision shall be communicated to the plan, the enrollee and the health care provider within 30 days of the receipt of all supporting information reasonably necessary to complete the review. The plan shall give the enrollee and the health care provider written or electronic confirmation of its decision within 15-business days of communicating the decision.
(d) A grievance review decision shall comply with the requirements and time frames set out in §§ 9.705 and 9.707 (relating to internal grievance process; and external grievance process).
Subchapter L. CREDENTIALING Sec.
9.761. Provider credentialing. 9.762. Credentialing standards. 9.763. Nonphysician providers at facilty, agency or organizations. § 9.761. Provider credentialing.
(a) A plan shall establish, maintain and adhere to a health care provider credentialing system to evaluate and enroll qualified health care providers for the purpose of creating an adequate health care provider network. The credentialing system shall include policies and procedures for the following:
(1) Initial credentialing.
(2) Recredentialing at least every 3 years.
(3) Including in the initial credentialing and recredentialing process, a plan assessment of the participating health care providers' ability to provide urgent care and routine care, and their ability to enroll additional patients in the practice in accordance with standards adopted by the plan.
(4) Inclusion of enrollee satisfaction and quality assurance data in the recredentialing review.
(5) Restrictions or limitations.
(6) Termination of a health care provider's participation.
(7) In cases of denial or nonrenewals, notification to health care providers that includes a clear rationale for the decision.
(8) Evaluating credentials of health care providers who may be directly accessed for obstetrical and gynecological care.
(9) Evaluating credentials for specialists who are being requested to serve as primary care providers, including standing referral situations, to ensure that access to primary health care services remain available throughout the arrangement.
(10) Enrollee access to only those participating providers who have been properly credentialed.
(b) The plan shall submit its credentialing plan to the Department for approval. Changes to the credentialing plan shall also be submitted to the Department for approval before implementation.
(c) A plan may meet the requirements of this section by establishing a credentialing system that meets or exceeds standards of a Nationally recognized accrediting body acceptable to the Department. The Department will publish a list of these bodies annually in the Pennsylvania Bulletin.
(d) A plan may not require full credentialing of nonparticipating health care providers providing health care services to new enrollees under the continuity of care provision. A plan may require verification of basic credentials such as licensure, malpractice insurance, hospital privileges and malpractice history as basic terms and conditions.
(e) Upon written request, a plan shall disclose relevant credentialing criteria and procedures to health care providers that apply to become participating providers or who are already participating.
(f) A plan shall submit a report to the Department regarding its credentialing process every 2 years. The report shall include the following:
(1) The number of applications made to the plan.
(2) The number of applications approved by the plan.
(3) The number of applications rejected by the plan.
(4) The number of providers terminated for reasons of quality.
(g) A plan shall comply with all requirements of section 2121 of the act (40 P. S. § 991.2121).
§ 9.762. Credentialing standards.
(a) At a minimum, for PCPS and specialists, a plan shall verify the following credentialing elements:
(1) Current licensure.
(2) Education and training.
(3) Board certification status.
(4) Drug enforcement administration certification status.
(5) Current and adequate malpractice coverage.
(6) Malpractice claims history.
(7) Work history.
(8) Hospital privileges if the provider provides services at hospitals.
(9) Any other information the Department may require.
(b) A plan shall verify, at a minimum, for non-PCPS and nonspecialists, current licensure and malpractice coverage, to the extent licensure and coverage is required by State or Federal law.
§ 9.763. Nonphysician providers at facility, agency or organizations.
A plan is not required to credential a nonphysician provider who practices as an employee or independent contractor of a plan-contracted facility, agency or organization if the plan verifies that the facility, agency or organization conducts credentialing that meets the standards of § 9.762 (relating to credentialing standards).
[Pa.B. Doc. No. 01-1032. Filed for public inspection June 8, 2001, 9:00 a.m.]
[31 Pa.B. 3175]
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