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Pennsylvania Statutes Title 40 P.S. Insurance § 991.2141a. Internal complaint process for enrollees

Current as of January 01, 2025 | Updated by Findlaw Staff

(a) An MA or CHIP managed care plan shall establish and maintain an internal complaint process by which an enrollee or the enrollee's authorized representative shall be able to file a complaint.

(b) The complaint process shall consist of a review to include all of the following:

(1) A review by a review committee consisting of one or more employes of the MA or CHIP managed care plan.

(2) The allowance of a written or oral complaint.

(3) The allowance of written data or other information.

(4) Written notification to the enrollee of the decision of the review committee within thirty (30) days of receipt of the complaint, unless the time frame for deciding the complaint has been extended by up to fourteen (14) days at the request of the enrollee.

(5) The written notification of the decision shall include the basis for the decision and the procedure to file a request for a second level review of the decision of the review committee, except as provided in paragraph (6).

(6) The written notification of the decision shall include the basis for the decision and the procedure to file an appeal of a complaint if the complaint is about one of the following:

(i) A denial because the service or item is not a covered service.

(ii) The failure of the MA or CHIP managed care plan to meet the required time frames for providing a service or item in a timely manner.

(iii) The failure of the MA or CHIP managed care plan to decide a complaint or grievance within the required time frames.

(iv) A denial of payment by the MA or CHIP managed care plan after the service or item has been delivered because the service or item was provided by a health care provider not enrolled in the medical assistance program.

(v) A denial of payment by the MA or CHIP managed care plan after the service or item has been delivered because the service or item provided is not a covered service or item for the enrollee.

(vi) A denial of an enrollee's request to dispute a financial liability.

(c) For all complaints except complaints listed in subsection (b)(6), the complaint process shall include a second level review that includes all of the following:

(1) A review of the decision of the review committee by a second level review committee consisting of three or more individuals who did not participate in the initial review. At least one-third of the second level review committee shall not be employed by the MA or CHIP managed care plan.

(2) A written notification to the enrollee of the right to appear before the second level review committee.

(3) A written notification to the enrollee of the decision of the second level review committee within forty-five (45) days of receipt of the second level complaint, which shall include the basis for the decision and the procedure for appealing the decision to the department.

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Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 991.2141a. Internal complaint process for enrollees - last updated January 01, 2025 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-991-2141a/

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