Pennsylvania Statutes Title 40 P.S. Insurance § 991.2155. Prior authorization review

(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:

(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.  1

(1) Upon receipt and review of a submission of a prior authorization request, an insurer or 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 or MA or CHIP managed care plan to make a prior authorization determination. An insurer or 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 subdivision.

(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.

(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:

(2) (Reserved).

(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:

(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 nonphysician 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.

(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).

(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.  2

(3) The following shall apply:

(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.

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

(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:

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

(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.