31 Pa. Code § 152.11 - Review of application by the Commissioner
(a) Upon receipt of a complete application
for approval for operation as a risk-assuming preferred provider organization,
the Commissioner will review the submitted materials to determine that the
following exist:
(1) The applicant is a
licensed insurer or has adequate working capital and reserves as defined in
§
152.9 (relating to minimum capital
and reserves).
(2) The applicant's
enrollee literature adequately discloses provisions, limitations and conditions
of benefits available.
(3) The
applicant's policy forms provide for emergency services as described in §
152.15 (relating to emergency
services).
(4) If the applicant is
not a licensed insurer, that:
(i) Its
preferred provider arrangements contain provisions to assure insolvency
protection as described in §
152.14 (relating to insolvency
protection).
(ii) Its policy forms
provide for a preexisting condition limitation as described in §
152.16 (relating to preexisting
condition limitation).
(iii) Its
officers and directors meet the qualifications in §
152.10(a)
(relating to qualification of officers and
directors).
(b)
Upon receipt of a complete application for approval by a preferred provider
organization which does not assume financial risk, the Commissioner will review
the submitted materials to determine that the applicant's enrollee literature
adequately discloses provisions, limitations and conditions of benefits
available.
(c) If the Commissioner
finds that the applicant meets the applicable standards in subsection (a) or
(b), the Commissioner will notify the applicant and the Secretary of the
determination.
(d) If the
Commissioner determines that an applicant does not meet the applicable
standards in subsection (a) or (b), the Commissioner will notify the applicant
of the disapproval, in writing, specifying the reason for the disapproval.
Within 30 days from the date of mailing of the notice to the preferred provider
organization, the preferred provider organization may make written application
to the Commissioner for a hearing. The hearing will be held within 30 days
after receipt of the application. The procedure before the Commissioner will be
under the adjudication procedure in
2
Pa.C.S. §§
501-508 and
701-704 (relating to the
Administrative Agency Law). The preferred provider organization is entitled to
judicial review as provided by statute.
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