Pennsylvania Statutes Title 40 P.S. Insurance § 991.2113. Medical gag clause prohibition

(1) The process that the insurer or MA or CHIP managed care plan or any entity contracting with the insurer or MA or CHIP managed care plan uses or proposes to use to deny payment for a health care service.

(2) Medically necessary and appropriate care with or on behalf of a covered person or enrollee, including information regarding the nature of treatment; risks of treatment; alternative treatments; or the availability of alternate therapies, consultation or tests.

(3) The decision of an insurer or MA or CHIP managed care plan to deny payment for a health care service.

(1) Advocating for medically necessary and appropriate health care consistent with the degree of learning and skill ordinarily possessed by a reputable health care provider practicing according to the applicable legal standard of care.

(2) Filing a complaint, grievance or external review pursuant to the procedures set forth in this article.

(3) Protesting a decision, policy or practice that the health care provider, consistent with the degree of learning and skill ordinarily possessed by a reputable health care provider practicing according to the applicable legal standard of care, reasonably believes interferes with the health care provider's ability to provide medically necessary and appropriate health care.

(1) Prohibit an insurer or MA or CHIP managed care plan from making a determination not to pay for a particular medical treatment, supply or service, enforcing reasonable peer review or utilization review protocols or making a determination that a health care provider has or has not complied with appropriate protocols.

(2) Be construed as requiring an insurer or MA or CHIP managed care plan to provide, reimburse for or cover counseling, referral or other health care services if the insurer or MA or CHIP managed care plan: