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PA Bulletin, Doc. No. 09-1202



Autism Review Process; Insurance Department Notice 2009-06

[39 Pa.B. 3365]
[Saturday, July 4, 2009]

   This notice is issued to all persons and entities impacted by section 635.2 of the act of Insurance Company Law of 1921 (P. L. 682, No. 284), added by section 2 of Act 62 of 2008 (40 P. S. § 764h) concerning the review process for any ''denial or partial denial by an insurer of a claim for diagnostic assessment of autism spectrum disorders or a claim for treatment of autism spectrum disorders'' (''autism related issues''). As specified in Act 62, ''a covered individual or an authorized representative [a ''challenger''] shall be entitled to an expedited internal review process pursuant to the procedures set forth in Article XXI, followed by an expedited independent external review process established and administered by the Insurance Department.''

   Unless Act 62 regulations are promulgated, the Insurance Department intends to utilize procedures for internal review and independent external review parallel to those set forth in Article XXI (specified in 40 P. S. § 991.2101 and 28 Pa. Code Ch. 9, Subch. I (relating to complaints and grievances). However, therewill be two exceptions with respect to requests for an expedited independent external review. First, there will be no provision for direct access by a plan to a Certified Utilization Review Entity (CRE) on weekends and State holidays. Second, the Insurance Department will assign a CRE within 2 business days of receiving the request for an expedited review.

   Further, the Insurance Department interprets Act 62 to entitle the challenger to an expedited review process for autism related issues, but not to preclude the challenger from a nonexpedited review process. A nonexpedited review process will be used if the challenger does not meet the expedited time frames or if the challenger opts for a nonexpedited review. For purposes of autism related issues, the Insurance Department will oversee both nonexpedited and expedited reviews.

   Requests for external reviews for autism related issues, whether expedited or nonexpedited, should be submitted to Office of Consumer Liaison, Attn: Autism Review, Insurance Department, 13th Floor, Strawberry Square, Harrisburg, PA 17120 by letter or ra-in-consumer

   Questions regarding this notice may be addressed to Cynthia Fillman, Director, Office of Consumer Liaison, Insurance Department, 13th Floor, Strawberry Square, Harrisburg, PA 17120 by letter or ra-in-consumer

Insurance Commissioner

[Pa.B. Doc. No. 09-1202. Filed for public inspection July 2, 2009, 9:00 a.m.]

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