Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 52 Pa.B. 7348 (November 26, 2022).

31 Pa. Code § 152.104. Filing requirements.

§ 152.104. Filing requirements.

 (a)  A PPO desiring to offer a gatekeeper product shall submit a formal product filing to the Division of HMOs/PPOs of the Department and the Bureau of Health Financing and Program Development of the Department of Health. Two copies shall be filed with each Department and shall include:

   (1)  The group master policy, certificate and enrollee literature. Adequate primary care benefits shall be provided when an enrollee seeks care from the enrollee’s primary care physician. Copayments may not be so high as to act as a barrier to an enrollee’s use of the primary care physician.

   (2)  Initial rates and rating methodology.

   (3)  Copies of preferred provider contracts, which should contain features required by the Department of Health in HMO contracts, including:

     (i)   NAIC/National Association of HMO Regulators enrollee hold harmless language.

     (ii)   A provision for a preferred provider to participate in activities of and abide by the decisions of the PPO’s quality assurance and utilization review committee.

     (iii)   A provision for a preferred provider to cooperate with and abide by the decisions of the PPO’s enrollee grievance system.

     (iv)   A provision for the preferred provider to abide by PPO rules and regulations for preferred providers, including those regarding hospital privileges, credentialing, in-office reviews and similar rules.

     (v)   A provision for the provider to provide the PPO and the Department of Health with access to enrollee medical records for the purposes of quality oversight and grievance resolution.

     (vi)   A provision for immediate termination of participation and preferred status if the provider is found to be harming patients.

   (4)  Provisions of the proposed quality assurance and utilization review systems, including staffing and professional qualifications of the medical director, quality assurance, utilization review and provider relations staff.

   (5)  A description of the proposed grievance system.

   (6)  A description of the PPO’s ability to collect data and meet the annual and quarterly reporting requirements of the Department of Health.

   (7)  A copy of a notice form to be used when an enrollee seeks care without first obtaining a referral from the enrollee’s primary care physician, adequately disclosing the benefit or reimbursement advantages, or both, of seeking care by or through the enrollee’s primary care physician.

 (b)  As is the usual and customary practice of the Department and the Department of Health, the filing will be approved by joint approval letter, and no final approval action will be taken by either Department until both Departments complete their review and find the application to be acceptable.

Source

   The provisions of this §  152.104 adopted September 27, 1991, effective September 28, 1991, 21 Pa.B. 4424.

Cross References

   This section cited in 31 Pa. Code §  152.104 (relating to definitions).



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