31 Pa. Code § 69.52 - Peer review procedures
(a) A
provider's bill shall be referred to a PRO only when circumstances or
conditions relating to medical and rehabilitative services provided cause a
prudent person, familiar with PRO procedures, standards and practices, to
believe it necessary that a PRO determine the reasonableness and necessity of
care, the appropriateness of the setting where the care is rendered, and the
appropriateness of the delivery of the care. An insurer shall notify a
provider, in writing, when referring bills for PRO review at the time of the
referral.
(b) An insurer shall make
a referral to a PRO within 90 days of the insurer's receipt of sufficient
documentation supporting the bill. An insurer shall pay bills for care that are
not referred to a PRO within 30 days after the insurer receives sufficient
documentation supporting the bill. If an insurer makes its referral after the
30th day and on or before the 90th day, the provider's bill for care shall be
paid.
(c) During an initial
determination, a PRO shall request in writing from the provider the records and
documents necessary to undertake its review. The PRO shall afford the provider
an opportunity to discuss the case with the reviewer and to submit information
to the reviewer prior to a final determination.
(d) A PRO's initial determination shall be
completed within 30 days after the receipt of requested information. When a
provider fails to respond to the PRO's inquiry or provide requested
information, a PRO may commence its review 30 days after the request for
information is postmarked. If additional information critical for the outcome
of the determination is submitted by a provider or requested by a PRO, the
30-day review period may be tolled up to 20 days for the information to be
received and taken into consideration.
(e) A PRO shall provide a written analysis,
including specific reasons for its decision, to insurers, which shall within 5
days of receipt, provide copies to providers and insureds. Without the written
analysis, the review may not be considered an initial determination and unpaid
provider bills subject to the review shall be paid by the insurer. An insurer
may request another initial determination if the request is made within 90 days
of its receipt of the bill and supporting documentation in accordance with
subsection (b). The written analysis of the initial determination shall notify
all parties that they have 30 days from the day the initial determination is
effected to request a reconsideration and the process and location for filing a
request for reconsideration.
(f) A
PRO's initial determination resulting in the denial of a provider's claim, in
whole or in part, shall be effected by a licensed practitioner of like
speciality or a licensed practitioner with experience providing and prescribing
the care subject to the review.
(g)
Absent a change of condition, a decision of not medically necessary by the PRO
is basis for an insurer to deny payment for similar services to the same
insured resulting from the same accident. The insured or subsequent provider
has the right to request a reconsideration of the initial determination for
subsequent treatment or services received or provided.
(h) An insurer, provider or insured may
request, in writing, reconsideration of the initial PRO determination within 30
days from the date the initial determination is effected. A PRO may set a
reasonable charge for a reconsideration but the charge for a reconsideration
may not exceed the charge for the initial review. An insurer shall make full
payment of the charge for reconsideration to the PRO, but the amount paid for
the reconsideration shall be ultimately borne by the party against whom a
reconsideration determination is made.
(i) A reconsideration shall be effected by a
licensed practitioner of like speciality as the provider subject to the
reconsideration review. The licensed practitioner effecting the reconsideration
review may not be the same licensed practitioner who rendered the PRO's initial
determination.
(j) A PRO shall
afford the party requesting reconsideration an opportunity to discuss the case
with the reviewer and to submit additional information identified by the
reviewer before making a final determination of the reconsideration.
(k) A reconsideration shall be based upon the
information that led to the initial determination, new information found in
medical records or additional evidence submitted by the requesting
party.
(l) A PRO shall complete a
reconsideration within 30 days after receipt of the information submitted under
subsection (k). If additional information critical for the outcome of the
determination is submitted by a provider or requested by a PRO, the 30-day
review period may be tolled up to 20 days for the information to be received
and taken into consideration. A PRO shall send written notification of the
reconsideration determination to the insurer, which shall within 5 days of
receipt provide copies to providers and insureds. The written notice shall
contain the basis and rationale for the reconsideration
determination.
(m) Upon
determination of a reconsideration by a PRO, an insurer, provider or insured
may appeal the determination to the courts.
(n) The insured may not be billed during the
peer review process.
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