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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1806 (March 30, 2024).

28 Pa. Code § 9.675. Delegation of medical management.

§ 9.675. Delegation of medical management.

 (a)  A plan may contract with an entity for the performance of medical management relating to the delivery of health care services to enrollees. The plan shall be responsible for assuring that the medical management contract meets the requirements of all applicable laws. The plan shall submit the medical management contract to the Department for review and approval. The Department will review a medical management contract within 45 days of receipt of the contract. If the Department does not approve or disapprove a contract within 45 days of receipt, the plan may use the contract and it shall be presumed to meet the requirements of all applicable laws. If, at any time, the Department finds that a contract is in violation of law, the plan shall correct the violation. Reimbursement information submitted to the Department under this paragraph may not be disclosed or produced for inspection or copying to a person other than the Secretary or the Secretary’s representatives without the consent of the plan which provided the information, unless otherwise ordered by a court.

 (b)  If the contractor is to perform UR, the contractor shall be certified in accordance with Subchapter K (relating to CREs).

 (c)  To secure Department approval, a medical management contract shall include the following:

   (1)  Reimbursement methods being used to reimburse the contractor which comply with section 2152(b) of the act (40 P. S. §  991.2152(b)) which relates to operational standards for CREs compensation.

   (2)  The standards for the plan’s oversight of the contractor.

 (d)  Acceptable plan oversight shall include:

   (1)  Written review and approval by the plan of the explicit standards to be utilized by the contractor in conducting quality assurance, UR or related medical management activities.

   (2)  Reporting by the contractor to the plan on at least a quarterly basis regarding the delegated activities concerning the arrangement or provision of health care services and the impact of the delegated activities on the quality and delivery of health care services to the plan’s enrollees.

   (3)  Annual random sample re-review and validation of the results of delegated responsibilities to ensure that the decisions made and activities undertaken by the contractor meet the agreed-upon standards in the contract.

   (4)  A written description of the relationship between the plan’s medical management staff and the contractor’s medical management staff.

   (5)  A requirement that the contractor will cooperate with and participate in quality assurance activities and studies undertaken by the plan that pertain to the enrollee populations served by the contractor, including submitting written reports of activities and accomplishments on plan directed and any contractor initiated activities to the plan’s quality assurance committee on at least a quarterly basis.

 (e)  With respect to medical management arrangements involving an HMO, the medical management contract shall include a statement by the contractor agreeing to submit itself to review as a part of the HMO’s external quality assurance assessment. See §  9.654 (relating to HMO external quality assurance assessment). A contractor may receive a separate review of its operations by an external quality review organization approved by the Department. The Department will consider the results of the review in its overall assessment provided the review satisfies the requirements of §  9.674 (relating to quality assurance standards).

Cross References

   This section cited in 28 Pa. Code §  9.634 (relating to delegation of HMO operations); and 28 Pa. Code §  9.724 (relating to plan-IDS contracts).

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