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Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164b. Notice of right to external review

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

(a) Timing of notice.--An insurer shall notify a covered person in writing of the covered person's right to request an external review under section 2164.5,  1 2164.6  2 or 2164.7  3 at the same time the insurer sends written notice in a form approved by the department of either of the following:

(1) An adverse benefit determination upon completion of the insurer's utilization review process.

(2) A final adverse benefit determination.

(b) Content of notice.--The notice shall include:

(1) The following, or substantially equivalent, language:

We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care providers who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested. You also have the right to a review of whether we have complied with the surprise billing and cost-sharing protections under the No Surprises Act.  4 You may submit a request for external review to the Pennsylvania Insurance Department.

(2) For a notice related to an adverse benefit determination, a statement informing the covered person that:

(i) If the covered person has a medical condition for which the time frame for completion of an expedited review of an adverse benefit determination under section 2164  5 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person, or the covered person's authorized representative, may file a request for an expedited external review at the same time as a request for an expedited review of an adverse benefit determination under section 2164. The IRO assigned to conduct the expedited external review shall determine whether the covered person is required to complete the expedited review of the adverse benefit determination prior to conducting the expedited external review. The request may be filed under section 2164.6 or 2164.7 if:

(A) The adverse benefit determination involves a denial of coverage based on a determination that the recommended or requested health care services are experimental or investigational.

(B) The covered person's treating health care provider certifies in writing that the recommended or requested health care services that are the subject of the adverse benefit determination would be significantly less effective if not promptly initiated.

(ii) The covered person or the covered person's authorized representative may file an appeal under the insurer's internal appeal process under section 2164, but shall be considered to have exhausted the insurer's internal appeal process for purposes of section 2164.4  6 and may immediately file a request for external review under section 2164.3  7 if:

(A) The insurer has not issued a written decision to the covered person or the covered person's authorized representative within 30 days following the date the covered person or the covered person's authorized representative files the appeal with the insurer.

(B) The covered person or the covered person's authorized representative has not requested or agreed to a delay.

(C) The insurer waives its internal claim and appeal process and the requirement for a covered person or covered person's authorized representative to exhaust the process before filing a request for an external review or an expedited external review.

(D) The insurer has failed to comply with the requirements of the internal claim and appeal process unless the failure or failures are based on de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the covered person or covered person's authorized representative.

(3) For a notice related to a final adverse benefit determination, a statement informing the covered person that:

(i) If the covered person has a medical condition for which the time frame for completion of a standard external review under section 2164.5 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or covered person's authorized representative may file a request for an expedited external review under section 2164.6.

(ii) If the final adverse benefit determination concerns:

(A) An admission, availability of care, continued stay or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person or the covered person's authorized representative may request an expedited external review under section 2164.6.

(B) A denial of coverage based on a determination that the recommended or requested health care service is experimental or investigational, the covered person or covered person's authorized representative may file a request for a standard external review to be conducted under section 2164.7.

(C) A written certification by the treating health care provider that the recommended or requested health care service that is the subject of the request would be significantly less effective if not promptly initiated, the covered person or the covered person's authorized representative may request an expedited external review to be conducted under section 2164.6.

(4) A copy of the description of both the standard and expedited external review procedures required by section 2136(c)  8 that highlights the provisions in the external review procedures regarding the opportunity to submit additional information and any forms used to process an external review.

(5) An authorization form, or other document approved by the department that complies with the requirements of 45 CFR 164.508 (relating to uses and disclosures for which an authorization is required), by which the covered person, for purposes of conducting an external review under this subdivision, authorizes the insurer and the covered person's treating health care provider to disclose protected health information, including medical records, concerning the covered person, that are pertinent to the external review.

1 40 P.S. § 991.2164e.
2 40 P.S. § 991.2164f.
3 40 P.S. § 991.2164g.
4 See 42 U.S.C.A. § 300gg-111.
5 40 P.S. § 991.2164.
6 40 P.S. § 991.2164d.
7 40 P.S. § 991.2164c.
8 40 P.S. § 991.2136.
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Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164b. Notice of right to external review - last updated January 01, 2025 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-991-2164b/

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