[29 Pa.B. 6409]
[Continued from previous Web Page] § 9.709. Expedited review.
(a) A plan shall make an expedited review procedure available to an enrollee if the enrollee's life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the review process in this subchapter. An enrollee may request from the plan an expedited review at any stage of the plan's review process.
(b) The plan's internal expedited review process shall be bound by the same rules and procedures as the second level grievance review process with the exception of time frames. It is the responsibility of the enrollee or the health care provider to provide information to the plan in an expedited manner to allow the plan to conform to this section.
(c) A plan shall conduct an expedited internal review and issue its decision within 48 hours of the enrollee's request for an expedited review.
(d) The notification to the enrollee shall state the basis for the decision, including any clinical rationale and the procedure for obtaining an expedited external review.
(e) The enrollee has 2 business days from the receipt of the expedited internal review decision to contact the plan to request an expedited external review.
(f) Within 1 business day of the enrollee request, the plan shall submit a request for an expedited external review to the Department by Fax transmission or telephone call. The Department will make information available to the plan to enable the plan to have direct access to a CRE on weekends and State holidays.
(g) The case will be referred to an external review entity and the Department will assign a CRE within 1 business day of receiving the request for an expedited review.
(h) When assigning a CRE, the Department will rely on information provided by the CRE as to any affiliations or contractual relationships with plans to avoid conflicts of interest.
(i) In all cases, the plan will transfer a copy of the case file to the review entity for receipt on the next business day and the CRE has 2 business days to issue a response.
(j) External expedited review decisions may be appealed to a court of competent jurisdiction.
§ 9.710. Approval of plan enrollee complaint and enrollee and provider grievance systems.
(a) The Department will review the plan's enrollee complaint and grievance systems under its authority to review the operations of the plan and its quality assurance systems, and complaint and grievance resolution systems, to ensure that they are satisfactory to the Secretary.
(b) If changes are made by the plan in procedure or in the description of the enrollee and provider complaint and grievance systems to ensure continued compliance, the plan shall submit a copy of the proposed changes to the Department for prior review.
(c) Complaint and grievance procedures for special populations, such as Medicaid and Medicare HMO enrollees, shall comply with Act 68 to the extent permitted by Federal law and regulation.
§ 9.711. Alternative provider dispute resolution systems.
(a) A plan and a health care provider may agree to an alternative dispute resolution system for the review and resolution of disputes between the health care provider and the plan. These disputes include denials based on procedural errors and administrative denials involving the level or types of health care service provided.
(b) Procedural errors and administrative denials in which the enrollee is held harmless by virtue of the provider contract or when the enrollee has never been advised by the plan in writing that continued health care services would not be covered benefits, will not be automatically viewed as grievances for the purposes of this subchapter and may be addressed by alternate dispute systems.
(c) The alternative dispute resolution procedure shall be included in the health care provider contract with the plan, and shall be enforceable. The contract shall contain a provision that a decision from the alternative dispute resolution system shall be final and binding on both the plan and health care provider.
(d) Nothing in this subchapter precludes a plan and its participating health care providers from creating and maintaining informal dispute resolution systems aimed at expediting the review and determination of problems prior to utilization of the formal grievance procedure.
(e) To be acceptable to the Department, a proposed alternative dispute solution system shall:
(1) Be impartial.
(2) Include specific and reasonable time frames in which to initiate appeals, receive written information, conduct hearings and render decisions.
(3) Provide for final review and determination of provider grievances.
(f) An alternative dispute resolution system may not be utilized for any external grievance filed by an enrollee.
Subchapter J. HEALTH CARE PROVIDER CONTRACTS Sec.
9.721. Applicability. 9.722. Plan and health care provider contracts. 9.723. IDS. 9.724. HMO-IDS provider contract. 9.725. IDS-provider contracts. § 9.712. Applicability.
This subchapter applies to provider contracts between managed care plans subject to Act 68 and health care providers; HMOs subject to the HMO Act and IDSs; and IDSs and health care providers.
§ 9.722. Plan and health care provider contracts.
(a) A plan shall submit the standard form of each type of health care provider contract to the Department for review and approval prior to implementation.
(b) The plan shall submit any change or amendment to a health care provider contract to the Department 10 days prior to implementation of the change or amendment.
(c) To be approved by the Department, a health care provider contract may not contain provisions permitting the plan to sanction, terminate or fail to renew a health care provider's participation for any of the following reasons:
(1) Advocating for medically necessary and appropriate health care services for an enrollee.
(2) Filing a grievance on behalf of and with the written consent of an enrollee, or helping an enrollee to file a grievance.
(3) Protesting a plan decision, policy or practice the health care provider believes interferes with its ability to provide medically necessary and appropriate health care.
(4) Taking another action specifically permitted by section 2113 the act (40 P. S. § 991.2113).
(d) To be approved by the Department, a health care provider contract may not contain any provision permitting the plan to penalize or restrict a health care provider from discussing any of the information health care providers are permitted to discuss under section 2113 of the act or other information the health care provider reasonably believes is necessary to provide to an enrollee full information concerning the health care of the enrollee.
(e) To be approved by the Department, a health care provider contract shall include the following consumer protection provisions:
(1) Enrollee hold harmless language which survives the termination of the health care provider contract regardless of the reason for termination, and includes the following:
(i) A statement that the hold harmless language is construed for the benefit of the enrollee.
(ii) A statement that the hold harmless language supersedes any written or oral agreement currently in existence, or entered into at a later date, between the health care provider and enrollee, or persons acting in their behalf.
(iii) Language to the following effect:
''In no event including, but not limited to, non-payment by the plan, plan insolvency, or a breach of this contract, shall the provider bill, charge, collect a deposit from, seek compensation or reimbursement from, or have any recourse against the enrollee or persons other than the plan acting on the behalf of the enrollee for services listed in this agreement. This provision does not prohibit collecting supplemental charges or co-payments in accordance with the terms of the applicable agreement between the plan and the enrollee.''(2) Language stating that enrollee records shall be kept confidential by the plan and the health care provider in accordance with section 2131 of the act (40 P. S. § 991.2131) and applicable State and Federal laws and regulations, which include:
(i) Language permitting the Department, the Insurance Department, and, when necessary, the Department of Public Welfare, access to records for the purpose of quality assurance, investigation of complaints or grievances, enforcement or other activities related to compliance with Article XXI, this chapter and other laws of the Commonwealth.
(ii) Language which states that records are only accessible to Department employes or agents with direct responsibilities under subparagraph (i).
(3) Language requiring the health care provider to participate in and abide by the decisions of the plan's quality assurance, UR and enrollee complaint and grievance systems.
(4) Language addressing any alternative dispute resolution systems.
(5) Language requiring the health provider to adhere to State and Federal laws and regulations, including State reporting requirements concerning communicable and noncommunicable diseases and conditions.
(6) Language concerning prompt payment of claims.
(7) Language requiring that the health care provider give at least 60 days advance written notice to the plan of termination of the provider contract.
(f) To be approved by the Department, a health care provider contract shall satisfy the following:
(1) Include the reimbursement method being used to reimburse a participating provider under the contract. If a provider reimbursement is subject to variability due to economic incentives, including bonus incentive systems, withhold pools or similar systems, the plan shall describe the systems and the factors being employed by the plan to determine reimbursement when the contract is submitted to the Department for review.
(2) Include no incentive reimbursement system for licensed professional health care providers which shall weigh utilization performance as a single component more highly than quality of care, enrollee services and other factors collectively.
(3) Include no financial incentive that compensates a health care provider for providing less than medically necessary and appropriate care to an enrollee.
§ 9.723. IDS.
(a) IDS contracts between the IDS and the HMO and between the IDS and the health care provider shall meet the standards of health care provider contracts in § 9.722 (relating to plan and health care provider contracts).
(b) An HMO and an IDS entering into an arrangement under this subchapter shall notify the Department in writing at least 60 days in advance of any proposed action which would result in the IDS's participating providers being unavailable to provide covered services to enrollees, including institution of litigation, termination or nonrenewal notice by either party.
§ 9.724. HMO-IDS provider contract.
(a) An HMO may contract with an IDS for the provision of care by IDS participating health care providers to HMO enrollees.
(b) To avoid the necessity of renegotiation under section 8(a) of the HMO Act (40 P. S. § 1558(a)), the HMO shall provide a copy of the HMO-IDS contract for review and approval prior to implementation.
(c) Along with the HMO-IDS contract, the HMO shall provide copies of contracts between the IDS and its participating health care providers for the Department's review and approval. For the Department to approve a contract between the HMO and the IDS, the contract shall meet the following standards:
(1) An IDS, assuming financial risk from a HMO, is not required to obtain its own license to assume the risk, provided that the ultimate responsibility for provision of care to enrollees remains, as set forth in the enrollee contract, the responsibility of the HMO, unless the IDS does the following:
(i) Solicits or enrolls members in a plan that will deliver prepaid basic health care services.
(ii) Delivers prepaid basic health care services to those members.
(2) If a person or entity is delivering prepaid basic health care services to enrollees, but not soliciting or enrolling members in a plan, that person or entity is not required to obtain a certificate of authority. If the person or entity is delivering prepaid basic health care services and performing administrative services or other similar functions, but not soliciting or enrolling HMO members, that person or entity is not required to obtain a certificate of authority.
(3) The IDS shall acknowledge and agree that under no circumstance shall provision of covered services to enrollees be delayed, reduced, denied or otherwise hindered because of the financial or contractual relationship between the HMO and the IDS or between the IDS and the participating health care providers.
(4) The IDS shall acknowledge and agree that only those IDS participating health care providers who meet the HMO's credentialing and provider contracting standards may participate and provide services to enrollees and that the ultimate authority to approve or terminate IDS health care providers is retained by the HMO.
(5) The IDS shall acknowledge and agree that the HMO is required to establish, operate and maintain a health care services delivery system, quality assurance system, provider credentialing system, enrollee complaint and grievance system, and other systems meeting Department standards and that the HMO is directly accountable to the Department for compliance with the standards and for provision of high quality, cost-effective care to HMO enrollees. Nothing in the HMO-IDS contract may limit the HMO's authority or responsibility to meet standards or to take prompt corrective action to address a quality of care problem, resolve an enrollee complaint or grievance, or to comply with a regulatory requirement of the Department.
(6) The IDS shall agree to provide the HMO and the Department with access to medical and other records concerning the provision of services to enrollees by the IDS through its participating health care providers. The IDS shall agree to permit and cooperate with onsite reviews by the Department for purposes of monitoring the effectiveness of the IDS performance of any HMO-delegated functions.
(7) The IDS shall agree that any delegation of authority or responsibility, in part or in full, for provider credentialing and relations, quality assessment, UR and other HMO functions to the IDS shall be subject to performance monitoring by the HMO and Department, and is subject to independent validation by the HMO, the Department, or an independent quality review organization or CRE approved by the Department.
(8) The IDS shall agree to collect and provide the HMO with utilization, financial and other data for the purposes of monitoring and comparative performance analysis.
(9) The IDS shall agree to comply with data reporting requirements, including encounter, utilization and reimbursement methodology required by the Department.
(10) The IDS shall obtain and maintain Department certification as a CRE if performing UR activities in Subchapter F (relating to CREs) and sections 2151 and 2152 of the act (40 P. S. §§ 991.2151 and 991.2152).
(11) The HMO-IDS contract shall contain enrollee financial hold-harmless provisions acceptable to the Department which prevent the IDS and IDS participating health care providers from billing HMO enrollees for covered services (other than authorized co-payments, co-insurance or deductibles) under any circumstances including insolvency of the HMO or the IDS.
(12) The HMO-IDS contract shall safeguard patient access to care and avoid significant disruption of service delivery by adequately providing for continuation of services by IDS participating health care providers to HMO enrollees if the HMO-IDS contractual agreement is in any way jeopardized, suspended, terminated or unexpectedly not renewed. In the event of termination, the HMO shall ensure continuity of care for those affected enrollees, under Act 68 and § 9.684 (relating to continuity of care).
(13) The HMO-IDS contract shall contain a provision allowing either party to terminate without cause upon at least 60 days prior written notice.
(14) Any delegation of medical management shall meet the requirements of § 9.675 (relating to delegation of medical management).
§ 9.725. IDS-provider contracts.
In addition to the HMO-IDS contract, the health care provider contracts between the IDS and its participating health care providers shall be submitted for review and approval to the Department. To secure Department approval of a contract between the HMO and the IDS, an IDS-health care provider contract shall meet the following standards:
(1) The health care provider shall acknowledge and agree that nothing in the IDS-provider contract limits the following:
(i) The authority of the HMO to ensure the health care provider's participation in and compliance with the HMO's quality assurance, utilization management, enrollee complaint and grievance systems and procedures or limits.
(ii) The Department's authority to monitor the effectiveness of the HMO's system and procedures or the extent to which the HMO adequately monitors any function delegated to the IDS, or to require the HMO to take prompt corrective action regarding quality of care or consumer grievances and complaints.
(iii) The HMO's authority to sanction or terminate a health care provider found to be providing inadequate or poor quality care or failing to comply with HMO systems, standards or procedures as agreed to by the IDS.
(2) An IDS health care provider shall acknowledge and agree that any delegation by the HMO to the IDS for performance of quality assurance, utilization management, credentialing, provider relations and other medical management systems shall be subject to the HMO's oversight and monitoring of IDS performance.
(3) An IDS health care provider shall acknowledge and agree that the HMO, upon failure of the IDS to properly implement and administer the systems, or to take prompt corrective action after identifying quality, enrollee satisfaction or other problems, may terminate its contract with IDS, and that as a result of the termination, the health care provider's participation in the HMO may also be terminated.
(4) The IDS provider contract shall contain enrollee financial hold-harmless provisions acceptable to the Department which prevent the IDS and an IDS participating health care provider from billing HMO enrollees for covered services (other than authorized co-payments, co-insurance, or deductibles) under any circumstances including insolvency of the HMO or the IDS.
Subchapter K. CREs Sec.
9.741. Applicability. 9.742. CREs. 9.743. Content of an application for certification as a CRE. 9.744. CREs participating in internal and external grievance reviews. 9.745. Responsible applicant. 9.746. Fees for certification and recertification of UR entities. 9.747. Department review and approval of a certification request. 9.748. Maintenance and renewal of CRE certification. § 9.741. Applicability.
This subchapter sets standards for the certification of CREs and the maintenance of that certification.
§ 9.742. CREs.
(a) To conduct UR activities, including review of health care services delivered or proposed to be delivered in this Commonwealth for or on behalf of a plan, an entity shall be certified as a CRE by the Department.
(b) Certification shall be renewed every 3 years unless otherwise subjected to additional review, suspended or revoked by the Department. The Department may subject a CRE to additional review, suspend or revoke certification if it determines that the CRE is failing to comply with Act 68 and this chapter.
(c) A licensed insurer or a plan with a certificate of authority shall comply with section 2152 of the act (40 P. S. § 991.2152), but is not required to obtain separate certification as a CRE.
§ 9.743. Content of an application for certification as a CRE.
(a) A CRE seeking certification shall submit two copies of the Department's application to the Department's Bureau of Managed Care.
(b) The Department may make changes to the application form. The changes shall be published in the Pennsylvania Bulletin at least 30 days prior to the effective date of the changes.
(c) The application shall contain the following:
(1) The name, address and telephone number of the entity as it should appear on the Department's official list of certified CREs.
(2) Information relating to its organization, structure and function, including the following:
(i) The location of the principal office handling UR.
(ii) The articles of incorporation and bylaws, or similar documents regulating the internal affairs of the applicant.
(iii) The name of each owner of more than 5% of the shares of the corporation, if the applicant is a public corporation.
(iv) A chart showing the internal organization of the applicant's management and administrative staff.
(3) The names and resumes of each officer, director and senior management.
(4) A listing of each plan in this Commonwealth for which the applicant currently conducts UR.
(5) A description of the applicant's:
(i) Ability to respond to each telephone call received as required by section 2152 of the act (40 P. S. § 991.2152), including toll-free telephone numbers and the applicant's system to provide access during nonbusiness hours.
(ii) Acceptable selection and credentialing procedures and criteria for physician and psychologist clinical peer reviewers.
(iii) Ability to arrange for a wide range of health care providers to conduct reviews. The applicant shall have access to a pool of clinical peer reviewers sufficient to reasonably assure that appropriately qualified reviewers will be available on a timely basis.
(iv) Procedures for protecting the confidentiality of medical records and certification that the applicant will comply with the confidentiality provisions in section 2131 of the act (40 P. S. § 991.2131) and other applicable State and Federal laws and regulations imposing confidentiality requirements.
(v) Procedures to ensure that a health care provider is able to verify that an individual requesting information on behalf of the plan is a representative of the plan.
(vi) Capacity to maintain a written record of UR decisions adverse to enrollees for at least 3 years, including a detailed justification and the required notifications to the health care provider and enrollee.
(vii) Evidence of approval, certification or accreditation received by a Nationally recognized accrediting body in the area of UR, if it has secured the approval, certification or accreditation.
(viii) The length of time the applicant has been operating in this Commonwealth, if applicable.
(ix) A list of three clients for which the applicant has conducted UR including the name, address, position and telephone number of a contact person for each client. The Department may contact these references for an assessment of the applicant's past performance and its ability to meet the timeframes for prospective, concurrent and retrospective UR in section 2152 of the act.
(d) The applicant shall certify that:
(1) Decisions resulting in a denial shall be made by a licensed physician in a same or similar specialty to the health care provider of the service in question.
(2) An approved licensed psychologist in a same or similar specialty to the health care provider of the service in question, if the review is of behavioral health services within the psychologist's scope of practice, and the psychologist's clinical experience provides sufficient experience to review that specific behavioral health car service. A licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug.
(3) Compensation from a plan to a CRE, employe, consultant or other person performing UR on its behalf does not contain incentives, direct or indirect, to approve or deny payment for the delivery of any health care service.
§ 9.744. CREs participating in internal and external grievance reviews.
(a) To be certified to review internal and external grievances, the applicant shall supply the following additional information to the Department for review, along with the application:
(1) The name and type of business of each corporation, affiliate or other organization that the applicant controls; the nature and extent of the affiliation or control; and a chart or list clearly identifying the relationship between the applicant and affiliates.
(2) The name, title, address and telephone number of a primary and at least one backup designee with whom the Department may communicate regarding assignment of external grievances and other issues.
(3) A disclosure of any potential conflict of interest which would preclude its review of an external grievance--for example, ownership of or affiliation with a competing plan or other health insurance company.
(4) A description of the applicant's:
(i) Capacity and procedures for notifying the health care provider of additional facts or documents required to complete the UR within 48 hours of receipt of the request for review.
(ii) Systems and procedures, including staffing and resources, to meet the time frames for decisions as specified in section 2152 of the act (40 P. S. § 991.2152). The applicant shall have access to a pool of clinical peer reviewers sufficient to reasonably assure that appropriately qualified reviewers will be available on a timely basis for internal and external grievance reviews.
(iii) Capability and agreement to receive and decide all external grievances, or just behavioral health grievances if so desired, and the process for ensuring that clinical peer reviewers, when making an external appeal determination concerning medical necessity, consider the clinical standards of the health care plan, the information provided concerning the enrollee, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the Federal government, National or professional medical societies, boards and associations.
(iv) The capacity, procedures and agreement to maintain the information obtained in the review of the grievances, including outcomes, for at least 3 years in a manner that is confidential and unavailable to any affiliated entity or person who may be a direct or indirect competitor to the plan being reviewed.
(v) A fee schedule for the conduct of grievance reviews. An applicant will not be certified as CRE unless the proposed fees for external reviews are determined to be reasonable by the Department.
(5) A certification that the following conditions apply:
(i) The CRE is willing and able to participate on a rotational basis in grievance reviews.
(ii) Internal and external grievances and expedited grievances will be reviewed and processed in accordance with Act 68 and Subchapter F (relating to complaints and grievances).
(b) The Department will add the name of each certified CRE to its rotational list of CREs certified to conduct external grievances.
§ 9.745. Responsible applicant.
(a) To be certified by the Department, an applicant for certification to perform UR seeking certification shall be a responsible person.
(1) To make this determination, the Department may review and verify the credentials of any officer, director or member of the management staff of the applicant.
(2) The Department may consider whether any of the officers, directors or management personnel have ever:
(i) Filed for bankruptcy.
(ii) Been convicted of a state or Federal offense related to health care.
(iii) Been listed by a state or Federal agency as debarred, excluded or otherwise ineligible for state or Federal program participation.
(iv) Been convicted of a criminal offense which would call in to question the individual's ability to operate a CRE.
(v) Have a history of malpractice or civil suits, penalties or judgments against them.
(b) To be determined a responsible person, an applicant shall demonstrate to the Department that it has the ability to perform URs and grievance reviews based on medical necessity and appropriateness, without bias.
§ 9.746. Fees for certification and recertification of CREs.
(a) A CRE applying for certification shall include a fee of $1,000 payable to the Commonwealth of Pennsylvania with its application. Applicants seeking certification for external grievance reviews shall include an additional $1,000. By _____ (Editor's Note: The blank refers to the effective date of adoption of this proposal.) each CRE that is already certified by the Department shall pay the fee to the Department.
(b) The fee for recertification is $500.
§ 9.747. Department review and approval of a certification request.
(a) The Department will review the application for certification as a CRE. If the Department finds deficiencies, it will notify the applicant, identifying the changes required to bring the applicant into compliance.
(b) The Department will have access to the applicant's books, records, staff, facilities and other information it finds necessary to determine an applicant's compliance with Act 68 and this subchapter. In lieu of a site visit and inspection, the Department may accept accreditation of the applicant by a Nationally recognized accrediting body whose standards meet or exceed the standards of Act 68 and this subchapter.
(c) If the applicant is not accredited by a Nationally recognized accrediting body whose standards are acceptable to the Department, the Department may provide the applicant with the option to undergo an onsite inspection by a Nationally recognized accrediting body whose standards meet or exceed the standards of Act 68 and this subchapter. The cost of the inspection shall be borne by the applicant.
§ 9.748. Maintenance and renewal of CRE certification.
(a) Maintenance. To determine whether a CRE is complying with Act 68 and this subchapter, and maintaining its certification during the 3-year certification period, the Department may do one or more of the following:
(1) Perform periodic onsite inspections.
(2) Require proof of the CRE's continuing accreditation by a Nationally recognized accrediting body whose standards meet or exceed the standards of Act 68 and this subchapter.
(3) Require an onsite inspection as set forth in § 9.747 (relating to Department review and approval of a certification request).
(b) Renewal.
(1) A CRE shall submit an application for renewal of certification to the Department along with the appropriate renewal fee at least 60 days prior to the expiration of the 3-year certification period.
(2) The renewal application shall include the following:
(i) Evidence of the CRE's continued accreditation by a Nationally recognized accrediting body whose standards meet or exceed the standards of Act 68 and this subchapter.
(ii) A certification that the CRE has complied with and will continue to comply with Act 68 and this subchapter.
(iii) An updating of the CRE's originally filed list of conflicts of interest and CRE contracts with plans.
(iv) A reaffirmation of certifications included in the CRE's original application.
(3) The Department may perform an onsite inspection at the CRE before approving renewal of certification, or may require an onsite inspection set forth in § 9.747.
Subchapter L. CREDENTIALING Sec.
9.761. Provider credentialing. § 9.761. Provider credentialing.
(a) A plan shall establish and maintain 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 2 years.
(3) Including in the initial credentialing and recredentialing process, a plan assessment of the participating health care providers' ability to provide urgent care appointments, routine appointments and routine physical examinations to enrolled patients, 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.
(b) The plan shall submit its credentialing plan to the Department prior to implementation. Changes to the credentialing plan shall also be submitted to the Department prior to 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 comply with section 2121 of the act (40 P. S. § 991.2121).
[Pa.B. Doc. No. 99-2161. Filed for public inspection December 17, 1999, 9:00 a.m.]
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