Pennsylvania Statutes Title 40 P.S. Insurance § 991.2152. Operational standards

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

(2) Protect the confidentiality of covered person or enrollee medical records as set forth in section 2131.  1

(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:

(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.