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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 § 9.704. Appeal of a complaint decision.

§ 9.704. Appeal of a complaint decision.

 (a)  An enrollee shall have 15 days from receipt of the second level review decision of a complaint to file an appeal of the decision with either the Department or the Insurance Department. The appeal shall be in writing unless the enrollee requests to file the appeal in an alternative format. The Department will make staff available to transcribe an oral appeal.

 (b)  The appeal from the enrollee shall include the following:

   (1)  The enrollee’s name, address and telephone number.

   (2)  Identification of the plan.

   (3)  The enrollee’s plan identification number.

   (4)  A brief description of the issue being appealed.

   (5)  The second level denial letter from the plan concerning the complaint.

 (c)  Upon the Department’s request, the plan shall forward the complaint file, including relevant contract language and all material considered as part of the first two reviews, within 30 days of the Department’s request.

 (d)  The plan and the enrollee may provide additional information for review and consideration to the Department. Each shall provide to the other copies of additional documents provided to the Department.

 (e)  The Department and the Insurance Department will determine the appropriate agency for the review.

 (f)  The enrollee may be represented by an attorney or other individual before the Department.

Cross References

   This section cited in 28 Pa. Code §  9.703 (relating to internal complaint process).

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