§ 69.53. PRO standards for operation.
(a) A PRO shall contract, in writing, jointly or separately with an insurer for the provision of peer review services as authorized by Act 6 and this chapter.
(b) A PRO may not mediate disputes over appropriate charges, costs or payments, and may not engage in administration of claims for insurers. A PRO engaging in claims administration shall establish a separate company to perform peer review services.
(c) A PRO shall reimburse providers the cost for copying of records at the current rate HCFA reimburses its contracted PRO.
(d) Written notice of determinations shall be mailed to the insurer within 3 working days of conclusion of a PRO’s review.
(e) A PRO shall apply National, or when appropriate, regional norms in conducting determinations. If National and regional norms do not exist, a PRO shall establish written criteria to be used in conducting its reviews based upon typical patterns of practice in the PRO’s geographic area of operation.
(f) A PRO shall maintain reasonable security and confidentiality practices to prevent unauthorized access to PRO records and information including training of employes in procedures to protect the confidentiality of information.
Cross References This section cited in 31 Pa. Code § 69.55 (relating to criteria for Department approval of a PRO).
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