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Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164a. External review applicability and scope

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

(a) Applicability.--The external review provisions of this subdivision shall apply to:

(1) An adverse benefit determination rendered by an insurer that are based on any of the following:

(i) Medical necessity.

(ii) Appropriateness of service.

(iii) Health care setting.

(iv) Level of care.

(v) Effectiveness of a covered benefit.

(2) Disputes regarding an insurer's compliance with the surprise billing and cost-sharing protections under sections 2799a-1 and 2799a-2 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 300gg-19) and regulations promulgated thereunder.

(b) Nonapplicability.--The external review provisions of this subdivision do not apply to:

(1) Complaints, which may be appealed under section 2142.  1

(2) Grievances, which may be reviewed under section 2162.  2

(3) Administrative denials, which may be appealed under section 2142.

(c) No minimum threshold.--The external review process is available to a covered person or covered person's authorized representative with respect to health care services of any monetary value. There is no minimum financial threshold for filing a request for external review.

1 40 P.S. § 991.2142.
2 40 P.S. § 991.2162.
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Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164a. External review applicability and scope - last updated January 01, 2025 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-991-2164a/

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