See the bold text below.  (Note that section 2155 below deals specifically with prior authorization).  

Section 2102. Definitions.

As used in this article, the following words and phrases shall have the meanings given to them in this section:

“Active clinical practice.” The practice of clinical medicine by a health care provider for an average of not less than twenty (20) hours per week.

“Administrative denial.” An adverse benefit determination of prior authorization, coverage or payment based on a lack of eligibility, failure to submit complete information or other failure to comply with an administrative policy. The term does not include an adverse benefit determination subject to the external review process as set forth in section 2164.1(a).

“Administrative policy.” A written document or collection of documents reflecting the terms of the contractual or operating relationship between an insurer or MA or CHIP managed care plan and a health care provider.

“Adverse benefit determination.” An adverse benefit determination may be any of the following:

(1) A determination by an insurer or a utilization review entity on behalf of an insurer that, based upon the information provided and upon application of utilization review, a request for a benefit under a health insurance policy does not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness or is determined to be experimental or investigational, such that the requested benefit is therefore denied, reduced or terminated or payment is not provided or made, in whole or in part, for the benefit.

(2) The denial, reduction, termination or failure to provide or make payment, in whole or in part, for a benefit based on a determination by an insurer of a person’s eligibility for coverage under a health insurance policy or noncompliance with an administrative policy.

(3) A rescission of coverage determination by an insurer.

“Agreement with the Department of Human Services.” An agreement between an MA or CHIP managed care plan and the Department of Human Services to manage the purchase and provision of services. The term includes a county or multicounty agreement with the Department of Human Services for behavioral health services.

“Applicable governmental guidelines.”  Clinical practice and associated guidelines issued under the authority of the United States Department of Health and Human Services, United States Food and Drug Administration, Centers for Disease Control and Prevention, Pennsylvania Department of Health or other similarly situated Federal or State agency, department or subunit thereof focused on the provision or regulation of medical care, prescription drugs or public health within the United States or this Commonwealth.

“Authorized representative.”  One of the following:

(1)  A person, including a health care provider, to whom a covered person or enrollee has given express written consent to represent the covered person or enrollee in a complaint, grievance, adverse benefit determination, internal appeal or external review process.

(2)  A person authorized by law to provide substituted consent for a covered person or enrollee.

(3)  A family member or treating health care provider involved in providing health care to a covered person or enrollee if the covered person or enrollee is incapacitated or unable to provide consent due to a medical emergency or as necessary to prevent a serious and imminent threat to the health or safety of the covered person or enrollee.

“Clean claim.”  A claim for payment for a health care service which has no defect or impropriety. A defect or impropriety shall include lack of required substantiating documentation or a particular circumstance requiring special treatment which prevents timely payment from being made on the claim. The term shall not include a claim from a health care provider who is under investigation for fraud or abuse regarding that claim.

“Clinical review criteria.”  The set of written screening procedures, decision abstracts, clinical protocols and practice guidelines used by an insurer or MA or CHIP managed care plan to determine the necessity and appropriateness of health care services.

“Closely-related service.”  A health care service subject to prior authorization that is closely related in purpose, diagnostic utility or designated health care billing code, and provided on the same date of service as an authorized service, such that a prudent health care provider, acting within the scope of the provider’s license and expertise, may reasonably be expected to perform the service in conjunction with or in lieu of the originally authorized service in response to minor differences in observed patient characteristics or needs for diagnostic information that were not readily identifiable until the provider was actually performing the originally authorized service. The term does not include an order for or administration of a prescription drug or any part of a series or course of treatments.

“Commissioner.”  The Insurance Commissioner of the Commonwealth.

“Complaint.”  A dispute or objection regarding a participating health care provider or the coverage, operations or management policies of an insurer or MA or CHIP managed care plan which has not been resolved by the insurer or MA or CHIP managed care plan and has been filed with the insurer, MA or CHIP managed care plan or department. The term does not include a grievance or an adverse benefit determination.

“Concurrent review.”  A review performed by an insurer or MA or CHIP managed care plan, or by a utilization review entity acting on behalf of an insurer or MA or CHIP managed care plan, of all reasonably necessary supporting information which occurs during a covered person’s or an enrollee’s hospital stay or course of treatment and results in a decision to approve or deny payment for the health care service.

“Covered benefit.”  A health care service as set forth in the terms of a health insurance policy or an agreement with the Department of Human Services.

“Covered person.”  A policyholder, subscriber or other individual who is entitled to receive health care services under a health insurance policy.

“Department.”  The Insurance Department of the Commonwealth.

“Discharge planning.”  The formal process for determining, prior to discharge from a facility, the coordination and management of care that a covered person or enrollee will receive following the discharge.

“Drug formulary.”  A listing of health insurance policy or MA or CHIP managed care plan preferred therapeutic drugs.

“Emergency service.”  A health care service provided to a covered person or enrollee after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:

(1)  placing the health of the covered person or enrollee in serious jeopardy or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy;

(2)  serious impairment to bodily functions; or

(3)  serious dysfunction of any bodily organ or part.

Emergency transportation or related emergency service provided by a licensed ambulance service shall constitute an emergency service.

“Enrollee.”  [Any policyholder, subscriber, covered person or other individual] An individual who is entitled to receive health care services under [a managed care plan] an agreement with the Department of Human Services.

“Evidence-based standard.”  Interventions and treatment approaches that have been proven effective through appropriate empirical analysis.

“Facility.”  A health care setting or institution providing health care services, including:

(1)  A general, special, psychiatric or rehabilitation hospital.

(2)  An ambulatory surgical facility.

(3)  A cancer treatment center.

(4)  A birth center.

(5)  A skilled nursing center.

(6)  An inpatient, outpatient or residential drug and alcohol treatment facility.

(7)  A facility licensed by the Department of Human Services’ Office of Mental Health and Substance Abuse Services.

(8)  A laboratory, imaging, diagnostic or other outpatient medical service or testing facility.

(9)  A health care provider office or clinic.

“Final adverse benefit determination.”  An adverse benefit determination that has been upheld by an insurer or a utilization review entity designated by the insurer at the completion of the insurer’s internal claim and appeal procedures as specified in section 2164.

“Grievance.”  [As provided in subdivision (i), a] A request to an MA or CHIP managed care plan by an enrollee or [a health care provider, with the written consent of the enrollee,] an enrollee’s authorized representative to have [a] an MA or CHIP managed care plan [or utilization review entity] reconsider a decision solely concerning the medical necessity [and], appropriateness, health care setting, level of care or effectiveness of a health care service. If the MA or CHIP managed care plan is unable to resolve the matter, a grievance may be filed regarding the decision that:

(1)  disapproves full or partial payment for a requested health care service;

(2)  approves the provision of a requested health care service for a lesser scope or duration than requested; or

(3)  disapproves payment for the provision of a requested health care service but approves payment for the provision of an alternative health care service.

The term does not include a complaint or an adverse benefit determination.

“Health care provider.”  A licensed hospital or health care facility, medical equipment supplier or person who is licensed, certified or otherwise regulated to provide health care services under the laws of this Commonwealth, including a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician’s assistant, chiropractor, dentist, pharmacist or an individual accredited or certified to provide behavioral health services. The term includes an individual providing emergency services under a licensed emergency medical services agency as defined in 35 Pa.C.S. § 8103 (relating to definitions).

“Health care service.”  Any covered treatment, admission, procedure, medical supplies and equipment or other services, including behavioral health, prescribed or otherwise provided or proposed to be provided by a health care provider to [an] a covered person or enrollee [under a managed care plan contract.]  for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease under the terms of either a health insurance policy or an agreement with the Department of Human Services.

“Health insurance policy.”  A policy, subscriber contract, certificate or plan issued by an insurer that provides medical or health care coverage. The term does not include any of the following:

(1)  An accident only policy.

(2)  A credit only policy.

(3)  A long-term care or disability income policy.

(4)  A specified disease policy.

(5)  A Medicare supplement policy.

(6)  A TRICARE policy, including a Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement policy.

(7)  A fixed indemnity policy.

(8)  A hospital indemnity policy.

(9)  A dental only policy.

(10)  A vision only policy.

(11)  A workers’ compensation policy.

(12)  An automobile medical payment policy under 75 Pa.C.S. (relating to vehicles).

(13)  A homeowner’s insurance policy.

(14)  Any other similar policies providing for limited benefits.

“Independent review organization” or “IRO.”  An entity approved by the department under section 2164.9 that conducts independent reviews of adverse benefit determinations, final adverse benefit determinations and grievances.

“Insurer.”  An entity licensed by the department that offers, issues or renews an individual or group health insurance policy that is offered or governed under any of the following:

(1)  This act, including section 630 and Article XXIV.

(2)  The act of December 29, 1972 (P.L.1701, No.364), known as the “Health Maintenance Organization Act.”

(3)  40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations).

The term does not include an entity operating as an MA or CHIP managed care plan.

[“Managed care plan.”  A health care plan that uses a gatekeeper to manage the utilization of health care services, integrates the financing and delivery of health care services to enrollees by arrangements with health care providers selected to participate on the basis of specific standards and provides financial incentives for enrollees to use the participating health care providers in accordance with procedures established by the plan. A managed care plan includes health care arranged through an entity operating under any of the following:

(1)  Section 630.

(2)  The act of December 29, 1972 (P.L.1701, No.364), known as the “Health Maintenance Organization Act.”

(3)  The act of December 14, 1992 (P.L.835, No.134), known as the “Fraternal Benefit Societies Code.”

(4)  40 Pa.C.S. Ch. 61 (relating to hospital plan corporations).

(5)  40 Pa.C.S. Ch. 63 (relating to professional health services plan corporations).

The term includes an entity, including a municipality, whether licensed or unlicensed, that contracts with or functions as a managed care plan to provide health care services to enrollees. The term does not include ancillary service plans or an indemnity arrangement which is primarily fee for service.]

“Medical Assistance or Children’s Health Insurance Program managed care plan” or “MA or CHIP managed care plan.”  A health care plan that uses a gatekeeper to manage the utilization of health care services by medical assistance or children’s health insurance program enrollees and integrates the financing and delivery of health care services.

“Medical or scientific evidence.”  Evidence found in any of the following sources:

(1)  A peer-reviewed scientific study published in or accepted for publication by a medical journal that meets nationally recognized requirements for scientific manuscripts and which journal submits most of its published articles for review by experts who are not part of the journal’s editorial staff.

(2)  Peer-reviewed medical literature, including literature relating to a therapy reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Limited for indexing in Excerpta Medica (EMBASE).

(3)  A medical journal recognized by the Secretary of Health and Human Services under section 1861(t)(2) of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395x(t)(2)).

(4)  One of the following standard reference compendia:

(i)  The American Hospital Formulary Service-Drug Information.

(ii)  DRUGDEX Information System.

(iii)  The American Dental Association Accepted Dental Therapeutics.

(iv)  The United States Pharmacopoeia-Drug Information.

(5)  Findings, studies or research conducted by or under the auspices of a United States government agency or nationally recognized Federal research institute, including:

(i)  The United States Agency for Healthcare Research and Quality.

(ii)  The National Institutes of Health.

(iii)  The National Cancer Institute.

(iv)  The National Academy of Sciences.

(v)  The United States Department of Health and Human Services.

(vi)  The Food and Drug Administration.

(vii)  Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services.

(6)  Other medical or scientific evidence that is comparable to the sources specified in paragraphs (1), (2), (3), (4) and (5).

“Medical policy.”  A written document adopted, maintained and applied by an insurer or MA or CHIP managed care plan that  combines the clinical review criteria and any additional administrative policy, as applicable, necessary to articulate the insurer’s or MA or CHIP managed care plan’s standards for coverage of a given health care service or set of health care services under the terms of a health insurance policy or an agreement with the Department of Human Services.

“Medication-assisted treatment.”  The use of United States Food and Drug Administration-approved medications along with treatment other than medication, as clinically indicated, to treat substance use disorders, including opioid use disorders.

“NAIC.”  The National Association of Insurance Commissioners.

“Nationally recognized medical standards.”  Clinical criteria, practice guidelines and related standards established by national quality and accreditation entities generally recognized in the United States health care industry.

“Participating health care provider.”  A health care provider that has entered into a contractual or operating relationship with an insurer or MA or CHIP managed care plan to participate in one or more designated networks of the insurer or MA or CHIP managed care plan and to provide health care services to covered persons or enrollees under the terms of the insurer’s administrative policy or an agreement with the Department of Human Services.

“Prescription drug.”  A drug or biological product, as both of those terms are defined in the act of November 24, 1976 (P.L.1163, No.259), referred to as the Generic Equivalent Drug Law.

“Primary care provider.”  A health care provider who, within the scope of the provider’s practice, supervises, coordinates, prescribes or otherwise provides or proposes to provide health care services to a covered person or enrollee, initiates a referral for specialist care and maintains continuity of care for the covered person or enrollee.

“Prior authorization.”  A prospective utilization review performed by an insurer or MA or CHIP managed care plan, or by a utilization review entity acting on behalf of an insurer or MA or CHIP managed care plan, of all reasonably necessary supporting information that occurs prior to the delivery or provision of a health care service and results in a decision to approve or deny payment for the health care service. The term includes step therapy and step therapy exception requests.

“Prior authorization request.”  A request for prior authorization of a health care service that meets an insurer’s or MA or CHIP managed care plan’s administrative policy requirements for such a request.

“Protected health information.”  Information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that identifies an individual who is the subject of the information or for which there is a reasonable basis to believe that the information could be used to identify an individual, that relates to any of the following:

(1)  The past, present or future physical, mental or behavioral health or condition of an individual or a member of the individual’s family.

(2)  The provision of health care services to an individual.

(3)  payment for the provision of health care services to an individual.

“Provider network.”  Participating health care providers designated by an insurer or MA or CHIP managed care plan to provide health care services under a health insurance policy or an agreement with the Department of Human Services.

“Provider portal.”  A designated section or functional software module accessible via an insurer’s or MA or CHIP managed care plan’s publicly accessible Internet website that facilitates health care provider submission of electronic prior authorization requests.

“Referral.”  A prior authorization from an insurer, MA or CHIP managed care plan or a participating health care provider that allows a covered person or enrollee to have one or more appointments with a health care provider for a health care service.

“Retrospective utilization review.”   Review of medical necessity performed by an insurer or MA or CHIP managed care plan, or by a utilization review entity acting on behalf of an insurer or MA or CHIP managed care plan, and conducted after health care services have been provided to a covered person or enrollee.

“Service area.”  The geographic area for which an insurer or MA or CHIP managed care plan is licensed or has been issued a certificate of authority.

“Specialist.”  A health care provider whose practice is not limited to primary health care services and who has additional postgraduate or specialized training, has board certification or practices in a licensed specialized area of health care. The term includes a health care provider who is not classified by an insurer or MA or CHIP managed care plan solely as a primary care provider.

“Step therapy.”  A course of treatment in which certain designated drugs or treatment protocols must be either contraindicated, or used and found to be ineffective, prior to approval of coverage of other designated drugs or treatment protocols. The term does not include requests for coverage of nonformulary drugs.

“Urgent health care service.”  A covered health care service subject to prior authorization that is delivered on an expedited basis for the treatment of an acute condition with symptoms of sufficient severity pursuant to a determination by a licensed treating physician, operating with the individual’s scope of practice and professional expertise, that the failure to provide the service is likely to result in serious, long-term health complications or a material deterioration in the covered person’s or enrollee’s condition and prognosis.

“Utilization review.”  A set of formal techniques designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy or efficiency of health care services, procedures or settings, including prior authorization, second opinion, certification, concurrent review, case management, discharge planning or retrospective review, in order to make a determination regarding coverage of the service under the terms of a health insurance policy or an agreement with the Department of Human Services.

“Utilization review entity.”  Any entity certified pursuant to subdivision (h) that performs utilization review on behalf of an insurer or MA or CHIP managed care plan.

See https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2022&sessInd=0&act=146

Section 2152. Operational standards

(a) A utilization review entity shall do all of the following:

(1) respond to inquiries relating to utilization review determinations by:

(i) providing toll-free telephone access at least forty (40) hours per week during normal business hours;

(ii) maintaining a telephone answering service or recording system during nonbusiness hours; and

(iii) responding to each telephone call received by the answering service or recording system regarding a utilization review determination within one (1) business day of the receipt of the call.

(2) Protect the confidentiality of covered person or enrollee medical records as set forth in section 2131.

(3) Ensure that a health care provider is able to verify that an individual requesting information on behalf of the insurer or MA or CHIP managed care plan is an authorized representative of the insurer or MA or CHIP managed care plan.

(4) Conduct utilization reviews based on the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service being reviewed.

(4.1) If performing a utilization review for a request for health care services for an covered person or enrollee of an insurer or MA or CHIP managed care plan, provide notification within the following time frames:

(i) a prior authorization decision shall be communicated within the time frame specified in section 2155.

State Medical Necessity Decisions-Deadlines

(ii) A concurrent utilization review decision shall be communicated within one (1) business day of the receipt of all supporting information reasonably necessary to complete the review.

(iii) A retrospective utilization review decision shall be communicated within thirty (30) days of the receipt of all supporting information reasonably necessary to complete the review.

(5) Ensure that personnel conducting a utilization review have current licenses in good standing or other required credentials, without restrictions, from the appropriate agency.

(6) Provide all decisions in writing to include the basis and clinical rationale for the decision.

(7) Notify the health care provider of additional facts or documents required to complete the utilization review within the time frames specified in section 2155.

(8) Maintain a written record of utilization review decisions adverse to covered persons or enrollees for not less than three (3) years, including a detailed justification and all required notifications to the health care provider and the covered person or enrollee.

(b) Compensation to any person or entity performing utilization review may not contain incentives, direct or indirect, for the person or entity to approve or deny payment for the delivery of any health care service.

(C) Utilization review that results in a denial of payment for a health care service shall be made by a licensed physician that meets the qualifications in section 2155(D), except as provided in subsections (D) and (E).

(D) A licensed psychologist may perform a utilization review for behavioral health care services within the psychologist’s scope of practice if the psychologist’s clinical experience provides sufficient experience to review that specific behavioral health care service. The use of a licensed psychologist to perform a utilization review of a behavioral health care service shall be approved by the department as part of the certification process under section 2151. A licensed psychologist shall not review the denial of payment for a health care service involving inpatient care or a prescription drug.

(E) A licensed dentist may perform a utilization review for dental services within the dentist’s scope of practice if the dentist’s clinical experience provides sufficient experience to review that specific dental service. The use of a licensed dentist to perform a utilization review of a dental service shall be approved by the department as part of the certification process under section 2151.

See https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2022&sessInd=0&act=146

Section 2154. Medical policies and clinical review criteria.

(a) Medical policies.

(1) An insurer or MA or CHIP managed care plan shall make available its current medical policies through the insurer’s or MA or CHIP managed care plan’s publicly accessible internet website and provider portal.

(2) Each medical policy developed by an insurer or MA or CHIP managed care plan shall identify the clinical review criteria used in the policy’s development. The insurer or MA or CHIP managed care plan shall identify any third-party licensure restrictions preventing disclosure of all or part of clinical review criteria.

(3) an insurer or MA or CHIP managed care plan shall review each adopted medical policy on at least an annual basis.

Amendments

(4)(i) An insurer or MA or CHIP managed care plan shall notify providers of a change to a medical policy as follows:

(A) In the case of a policy change due to a change in federal or state law or binding agency guidance, when the required implementation date of that policy change is sooner than 30 days, as soon as practicable;

(B) in the case of a change to a medical policy that modifies, eliminates or suspends either clinical or administrative criteria and that directly results in less restrictive coverage of a given service, within 30 days after application of the change.

(C) in cases other than in clauses (A) and (B), at least 30 days prior to application of the change.

(ii) a notification of change may be provided through reasonable means, including posting of an updated and dated medical policy reflecting the change.

U.R. Criteria

(b) Clinical review criteria.

(1) Clinical review criteria adopted by an insurer or MA or CHIP managed care plan shall, at the time of medical policy development or review:

(i) be based on applicable nationally recognized medical standards.

(ii) be consistent with applicable governmental guidelines.

(iii) provide for the delivery of a health care service in a clinically appropriate type, frequency and setting and for a clinically appropriate duration.

(iv) reflect the current medical and scientific evidence regarding emerging procedures, clinical guidelines and best practices as articulated in independent, peer-reviewed medical literature.

(2) Nothing in this act shall require an insurer or MA or CHIP managed care plan to provide coverage for a health care service to a covered person or enrollee that is otherwise excluded from coverage under a health insurance policy or an agreement with the department of human services.

This section is codified at https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2022&sessInd=0&act=146

Sections 2155. Prior Authorization Review.

(a) General rule.

(1) An insurer or MA or CHIP managed care plan shall make a determination relating to a request for prior authorization based on the insurer’s or MA or CHIP managed care plan’s review of a prior authorization request and the following:

(i) the insurer’s or MA or CHIP managed care plan’s medical policy.

(ii) the insurer’s or MA or CHIP managed care plan’s administrative policy.

(iii) all relevant medical information related to the enrollee or covered person.

(iv) any medical or scientific evidence submitted by the requesting provider.

(2) At the time of review, an insurer or MA or CHIP managed care plan shall verify the covered person’s or enrollee’s eligibility for coverage under the terms of the applicable health insurance policy or an agreement with the department of human services.

(3) Appeals of administrative denials shall be subject to the complaint process in section 2142.

(b) List of services subject to review. An insurer or MA or CHIP managed care plan shall make available a list, posted in a publicly accessible format and location on the insurer’s or MA or CHIP managed care plan’s publicly accessible internet website, that indicates the health care services for which the insurer or MA or CHIP managed care plan requires prior authorization.

(c) Information submission.

(1) Upon receipt and review of a submission of a prior authorization request, an insurer, MA or CHIP managed care plan shall notify the health care provider submitting the prior authorization request of any missing information needed by the insurer, MA or CHIP managed care plan to  make a prior authorization determination. An insurer, MA or CHIP managed care plan shall identify the missing information necessary to make a prior authorization determination with sufficient specificity to enable the health care provider to submit the missing information to  allow the insurer to make a determination in accordance with this chapter.

(2) If an insurer or MA or CHIP managed care plan requires a participating health care provider to transmit medical records in support of a prior authorization request electronically, and a health care provider is capable of transmitting medical records in support of a prior authorization request electronically, the health care provider shall ensure that the insurer or MA or CHIP managed care plan has electronic access to the medical records, including ability to print any medical records transmitted electronically, subject to applicable law and the health care provider’s corporate policies. The inability of a health care provider to provide electronic access shall not constitute a reason to deny an authorization request.

(d) Clinical knowledge of reviewer.

(1) Other than an administrative denial of a prior authorization request, a request for prior authorization may only be denied upon review by either of the following:

(i) a licensed health care provider with appropriate training, knowledge or experience in the same or similar specialty that typically manages or consults on the health care service in question; or

(ii) a licensed health care provider, in consultation with an appropriately qualified third-party health care provider, licensed in the same or similar medical specialty as the requesting health care provider or type of health care provider that typically manages the covered person’s or enrollee’s associated condition. Any compensation paid to the consulting health care provider may not be contingent upon the outcome of the review.

(2) (Reserved).

(e) Peer-to-peer review available. In the case of a denied prior authorization request other than an administrative denial, an insurer or MA  or CHIP managed care plan shall make available to the requesting provider a licensed health care professional for a peer-to-peer review discussion. The peer-to-peer reviewer provided by the insurer or MA or CHIP managed care plan shall meet the standards specified in subsection (d) and have authority to modify or overturn the prior authorization decision. The following shall apply:

(1) The procedure for requesting a peer-to-peer review discussion, including contact information for the insurer or its utilization review entity, or MA or CHIP managed care plan or its utilization review entity, shall be available on the insurer’s or MA or CHIP managed care plan’s publicly accessible internet website and provider portal.

(2) A provider may request a peer-to-peer review discussion:

(i) during normal business hours.

(ii) outside normal business hours, subject to reasonable limitations on the availability of qualified insurer or MA or CHIP managed care plan or utilization review entity staff.

(f) Peer-to-peer proxy.

(1) A health care provider may designate, and an insurer or MA or CHIP managed care plan shall accept, another licensed member of the provider’s affiliated or employed clinical staff with knowledge of the covered person’s or enrollee’s condition and requested procedure as a qualified proxy for purposes of completing a peer-to-peer discussion.

(2) Individuals eligible to receive a proxy designation shall be limited to licensed health care providers whose actual authority and scope of practice is inclusive of performing or prescribing the requested health care service.

(3) Authority may be established through a supervising health care provider consistent with applicable state law for non-physician practitioners.

(4) The insurer or MA or CHIP managed care plan must accept and review the information submitted by other members of a health care provider’s affiliated or employed staff in support of a prior authorization request.

(5) The insurer or MA or CHIP managed care plan may not limit interactions with an insurer’s or MA or CHIP managed care plan’s clinical staff solely to the requesting health care provider.

(g) Peer-to-peer timeline.

(1) A peer-to-peer-review discussion shall be available to a requesting health care provider from the time of a prior authorization denial until the internal grievance process or internal adverse benefit determination process commences.

(2) If a peer-to-peer review discussion is available prior to the insurer or MA or CHIP managed care plan making a decision on the prior authorization request, the peer-to-peer  review  discussion shall be offered  within the time lines specified in this subsection or subsection (h)   or (i).

(h) Review time lines for requests submitted to an MA or CHIP managed care plan.

(1) An MA or CHIP managed care plan’s decision to approve or deny a prior authorization  request shall be communicated within two business days of the receipt of all supporting information reasonably necessary to complete the review.

(2) If at any time after requesting prior authorization the provider determines the enrollee’s medical condition requires emergency services, the emergency services may be provided under section 2116.

(3) The following shall apply:

(i) If a prior authorization request is missing clinical information that is reasonably necessary to constitute a prior authorization request, the MA or CHIP managed care plan shall notify the health care provider of the specific information necessary to complete the review as soon as possible, but not later than 48 hours after receipt of the prior authorization request.

(ii) The requesting health care provider or a member of the requesting health care provider’s clinical or administrative staff may submit the specified information within 14 days of the notification that clinical information is missing.

(iii) If additional information is requested, the MA or CHIP managed care plan shall communicate a decision on the prior authorization request within two business days of receiving the additional information.

(4) An MA or CHIP managed care plan may supplement submitted information based on current clinical records or other current medical information for an enrollee as available, if the supplemental information is also made available to the enrollee or health care provider as part of the enrollee’s authorization case file upon request. In response to a request for missing clinical information, an MA or CHIP managed care plan shall accept supplemental information from a member of the health care provider’s clinical staff.

State Medical Necessity Decisions-Deadlines

(i) Review time lines for requests submitted to insurers. Determinations on prior authorization requests that may be subject to the adverse benefit determination processes shall be in accordance with the following, unless otherwise required by federal law or regulation:

(1) For a request related to an urgent health care service:

(i) If the urgent health care service has not yet been initiated, as soon as possible, but not more than 72 hours.

(ii) If related to an ongoing urgent health care service and the request is made at least 24 hours prior to reduction or termination of the treatment, within 24 hours.

(2) For a request involving concurrent care other than as set forth in paragraph (1)(ii), sufficiently in advance to permit an appeal before reduction or termination of the ongoing treatment.

(3) For prior authorization requests other than as specified in subparagraph (i), within 15 days. The following apply:

(i) The 15-day deadline may be extended by the insurer if all of the following apply:

(A) upon receipt of the prior authorization request, the insurer provided notification of missing information pursuant to subsection (c)(1); and

(B) the notification of missing information was communicated as soon as possible following the submission of the prior authorization request to allow an opportunity to respond prior to the expiration of the 15-day deadline with the identified missing information.

(ii) If the insurer grants an extension, the insurer may extend the deadline for at least 45 days to allow the provider to respond. Upon receipt of the missing information, the insurer shall render a decision without delay.

(iii) No insurer shall unreasonably delay or withhold the specific notice of additional information needed to complete a review of a prior authorization request.

(iv) Nothing in this paragraph shall require an insurer to extend the initial 15-day deadline.

(4) For a request related to a prescription drug authorization request or step therapy request:

(i) if the request is urgent, within 24 hours.

(ii) if the request is not urgent, within two business days, but not more than 72 hours.

(j) Closely related services. If a health care provider performs a closely related service, an insurer or MA or CHIP managed care plan may not deny a claim for the closely related service for failure of the health care provider to seek or obtain prior authorization, if:

(1) The health care provider notifies the insurer or MA or CHIP managed care plan of the performance of the closely related service no later than three business days following completion of the service but prior to the submission of the claim for payment. The submission of the notification shall include the submission of all relevant clinical information necessary for the insurer or MA or CHIP managed care plan to evaluate the medical necessity and appropriateness of the service.

(2) Nothing in this subsection shall be construed to limit an insurer’s or MA or CHIP managed care plan’s retrospective utilization review of medical necessity and appropriateness of the closely related service, nor limit the need for verification of the covered person’s or enrollee’s eligibility for coverage.

(k) Notice and statement. An insurer, when sending a notice to a covered person of a denial of a request for prior authorization made under this section, shall include with such notice the following statement:

THE STATEMENT BELOW IS REQUIRED BY PENNSYLVANIA STATE LAW.

Actions you can take and how to get help.

You, or someone on your behalf, recently requested approval from your health insurance plan for a health care service or item. Your health insurance plan denied the request.

You have the right to ask your health insurance plan to change this decision. This is called an internal appeal. If the request is not approved after an internal appeal, your request may be eligible for a review by an independent third party. This is called an external review. The independent third party may change your health insurance plan’s decision.

Please read carefully the information your health insurance plan has provided with this insert. This information explains the reason(s) for the health insurance plan’s decision, as well as how to ask for an internal appeal or external review, including any deadlines and timing.

You should also feel free to contact your health insurance plan or the Pennsylvania Insurance Department to help you understand your rights and answer any questions. Contact information for both your health insurance plan and the department is included in the information your health insurance plan has provided.

This section is codified at https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2022&sessInd=0&act=146