31 Pa. Code § 69.26 - Complaint submissions to the Department by providers

(a) Before submitting a complaint to the Department, a provider shall first attempt to resolve the complaint in writing with the affected insurer and show evidence that the attempt at resolution failed. An insurer shall respond to complaint correspondence from a provider within 30 days of receipt.

(b) In submitting an unresolved complaint to the Department, a provider shall include the following information for each insured person:

(1) The name of the insured.

(2) The name of the provider.

(3) The name of the insurer.

(c) The following documentation shall be attached:

(1) A copy of the claim filed with the insurer.

(2) A copy of the explanation of benefits paid or denied by the insurer.

(3) A copy of the provider's complaint correspondence sent to the insurer.

(4) A copy of the insurer's response to the provider's complaint.

(5) A written explanation of why the provider disagrees with the insurer's decision.

(6) The name, address and telephone number of the insurer's representative answering the provider's complaint.

(7) The name and telephone number of a contact person in the provider's office.

(d) Questions or disputes regarding whether care conforms to professional standards of performance and is medically necessary shall be resolved in accordance with the peer review provisions of Act 6 and this chapter.

(e) The submission of a complaint to the Department will not alter the provider's obligation to adhere to the 30-day time line for requesting a reconsideration of a PRO determination.

(f) This section does not limit or restrict any person with an interest in a medical claim payment from making a complaint to the Department or another governmental unit having jurisdiction over any party to a medical claim.

Notes

31 Pa. Code § 69.26