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Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164l. External review reporting requirements

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

(a) Recordkeeping by IROs.--

(1) An IRO assigned under section 2162  1 or this subdivision to conduct an external review shall maintain written records in the aggregate for the entire Commonwealth and for each insurer or MA or CHIP managed care plan, on all requests for which the IRO conducted an external review during a calendar year.

(2) An IRO required to maintain written records under paragraph (1) on all requests for external review for which the IRO was assigned to conduct an external review shall submit to the department, upon request, a report in the format specified by the department.

(3) The report shall include in the aggregate, for the entire Commonwealth and for each insurer or MA or CHIP managed care plan:

(i) The total number of requests for external review.

(ii) The number of requests for external review resolve and, of those resolved, the number resolved upholding the grievance decision, adverse benefit determination or final adverse benefit determination and the number resolved reversing the grievance decision, adverse benefit determination or final adverse benefit determination.

(iii) The average length of time for external review request resolution.

(iv) A summary of the types of coverages or cases for which an external review was sought, provided in a format specified by the department.

(v) The number of external reviews under sections 2164.5  2 and 2164.7  3 that were terminated as the result of a reconsideration by the insurer of the adverse benefit determination or final adverse benefit determination after the receipt of additional information from the covered person or the covered person's authorized representative.

(vi) Other information the department may request or require.

(4) The IRO shall retain the written records required under this subsection for at least three years.

(b) Recordkeeping by insurers.--

(1) An insurer shall maintain written records in the aggregate, for the entire Commonwealth, for each type of health insurance policy offered by the insurer, on all requests for external review as to which the insurer receives notice from the department under this subdivision.

(2) An insurer required to maintain written records under paragraph (1) shall submit to the department, upon request, a report in the format specified by the department.

(3) The report shall include in the aggregate, for the entire Commonwealth and for each type of health insurance policy offered by the insurer:

(i) The total number of requests for external review.

(ii) Of the total number of requests for external review reported under subparagraph (i), the number of requests determined eligible for external review.

(iii) Other information the department may request or require.

(4) The insurer shall retain the written records required under this subsection for at least three years.

1 40 P.S. § 991.2162.
2 40 P.S. § 991.2164e.
3 40 P.S. § 991.2164g.
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Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164l. External review reporting requirements - last updated January 01, 2025 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-991-2164l/

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