§ 9.708. External grievance reviews by CREs.
(a) The assigned CRE shall review and issue a written decision within 60 days of the filing of the request for an external grievance review. The decision shall be sent to the enrollee and the enrollee’s representative, the health care provider, if the health care provider filed the grievance with enrollee consent, the plan, and the Department. The decision shall include the credentials of the individual reviewer, a list of the information considered in reaching the decision, the basis and clinical rationale for the decision, a brief statement of the decision, and the statement that the enrollee, and the enrollee’s representative, or the health care provider have 60 days from receipt of the decision to appeal to a court of competent jurisdiction.
(b) The assigned CRE shall review the second level grievance review decision based on whether the health care service denied by the internal grievance process is medically necessary and appropriate under the terms of the plan.
(c) The assigned CRE shall review all information considered by the plan in reaching any prior decision to deny coverage for the health care service in question, and information provided in § 9.707 (relating to external grievance process).
(d) The assigned CRE’s decision shall be made by either of the following:
(1) One or more physicians certified by a board approved by the American Board of Medical Specialties or the American Board of Osteopathic Specialties, practicing within the same or similar specialty that typically manages or recommends treatment for the health care service being reviewed.
(2) One or more licensed physicians or approved licensed psychologists in active clinical practice in the same or similar specialty that typically manages or recommends treatment for the health care service being reviewed.
(e) In reviewing a grievance decision relating to emergency services, the CRE shall utilize the emergency service standards of Act 68 and this chapter, the prudent layperson standard and the enrollee’s certificate of coverage.
Cross References This section cited in 28 Pa. Code § 9.707 (relating to external grievance process).
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