31 Pa. Code § 69.55 - Criteria for Department approval of a PRO
(a) A PRO shall apply in writing to the
Commissioner for approval to contract with an insurer to provide peer review
services in accordance with the act and this chapter. If the application is
disapproved, the PRO may appeal the disapproval to the Commissioner. If the
Commissioner determines that reasonable grounds exist to review the
disapproval, the Commissioner may schedule a hearing to review the
determination. The hearing shall be conducted in accordance with
2
Pa.C.S. §§
501-508 and
701-704 (relating to the
Administrative Agency Law).
(b) A
PRO applicant shall include in its written application the following
information:
(1) A Certification of
Independence. A PRO may not be owned by a Pennsylvania-licensed insurer. While
a PRO may be organized by one or more insurers, that PRO may not review the
claims of those insurers, may not be a subsidiary or affiliate of those
insurers' corporate structure and none of the PRO's officers or directors may
have a direct financial interest in the insurers. PRO personnel may not review
services provided to an insured by an institution or agency in which they have
financial interest.
(2) A
description of previous experience as a PRO and the length of time in
operation.
(3) A certification that
reviews are conducted by medical personnel licensed in this
Commonwealth.
(4) A compensation
policy. A PRO shall charge for its service on a flat fee or hourly rate basis.
A PRO may not charge for services on a percentage or contingency fee
basis.
(5) A quality assessment of
the PRO's review services, including examples of the PRO's review
procedures.
(6) A policy statement
on the preservation of the confidentiality of medical records.
Notes
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