Pennsylvania Statutes Title 40 P.S. Insurance § 991.2162. External grievance process

(1) The department shall randomly assign an IRO on a rotational basis from the list maintained under subsection (d) and notify the assigned IRO and the MA or CHIP managed care plan within two (2) business days of receiving the request. If the department fails to select an IRO under this subsection, the MA or CHIP managed care plan shall designate and notify a certified IRO to conduct the external grievance.

(2) Within the same two (2) business day time frame set forth in paragraph (1), the department shall notify the enrollee or the enrollee's authorized representative of the name, address, e-mail address, fax number and telephone number of the IRO assigned under this subsection. The notice shall inform the enrollee and the enrollee's authorized representative of the right to submit additional written information to the IRO within twenty (20) days of the date the IRO assignment notice was mailed and shall include instructions for submitting additional information to the IRO by mail, facsimile and electronically.

(1) Any external grievance shall be filed with the MA or CHIP managed care plan within fifteen (15) days of receipt of a notice of denial resulting from the internal grievance process. The filing of the external grievance shall include any material justification and all reasonably necessary supporting information. Within five (5) business days of the filing of an external grievance, the MA or CHIP managed care plan shall notify the enrollee, the enrollee's authorized representative or the health care provider and the department that an external grievance has been filed.

(2) The MA or CHIP managed care plan that conducted the internal grievance shall forward copies of all written documentation regarding the denial, including the decision, all reasonably necessary supporting information, a summary of applicable issues and the basis and clinical rationale for the decision, to the IRO conducting the external grievance within fifteen (15) days of receipt of notice that the external grievance was filed. Any additional written information may be submitted by the enrollee, the enrollee's authorized representative or the health care provider within twenty (20) days of the date the notice of the IRO assignment was mailed to the enrollee, the enrollee's authorized representative or health care provider.

(3) The IRO conducting the external grievance shall review all information considered in reaching any prior decisions to deny payment for the health care service and any other written submission by the enrollee, the enrollee's authorized representative or the health care provider.

(4) An external grievance decision shall be made by:

(5) Within sixty (60) days of the filing of the external grievance, the IRO conducting the external grievance shall issue a written decision to the MA or CHIP managed care plan, the enrollee, the enrollee's authorized representative if the enrollee's authorized representative requested the external review, and the health care provider, including the basis and clinical rationale for the decision. The standard of review shall be whether the health care service denied by the internal grievance process was medically necessary and appropriate under the terms of the agreement with the Department of Human Services. The external grievance decision shall be subject to appeal to a court of competent jurisdiction within sixty (60) days of receipt of notice of the external grievance decision. There shall be a rebuttable presumption in favor of the decision of the IRO conducting the external grievance.

(6) The MA or CHIP managed care plan shall authorize any health care service or pay a claim determined to be medically necessary and appropriate under paragraph (5) pursuant to section 2166 whether or not an appeal to a court of competent jurisdiction has been filed.

(7) All fees and costs related to an external grievance shall be paid by the nonprevailing party if the external grievance was filed by the health care provider and the health care provider was not the enrollee's authorized representative. The health care provider and the MA or CHIP managed care plan shall each place in escrow an amount equal to one-half of the estimated fees and costs of the external grievance process. If the external grievance was filed by the enrollee or the enrollee's authorized representative, all fees and costs related thereto shall be paid by the MA or CHIP managed care plan. For purposes of this paragraph, fees and costs shall not include attorney fees.