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 § 152.11. Review of application by the Commissioner.

§ 152.11. Review of application by the Commissioner.

 (a)  Upon receipt of a complete application for approval for operation as a risk-assuming preferred provider organization, the Commissioner will review the submitted materials to determine that the following exist:

   (1)  The applicant is a licensed insurer or has adequate working capital and reserves as defined in §  152.9 (relating to minimum capital and reserves).

   (2)  The applicant’s enrollee literature adequately discloses provisions, limitations and conditions of benefits available.

   (3)  The applicant’s policy forms provide for emergency services as described in §  152.15 (relating to emergency services).

   (4)  If the applicant is not a licensed insurer, that:

     (i)   Its preferred provider arrangements contain provisions to assure insolvency protection as described in §  152.14 (relating to insolvency protection).

     (ii)   Its policy forms provide for a preexisting condition limitation as described in §  152.16 (relating to preexisting condition limitation).

     (iii)   Its officers and directors meet the qualifications in §  152.10(a) (relating to qualification of officers and directors).

 (b)  Upon receipt of a complete application for approval by a preferred provider organization which does not assume financial risk, the Commissioner will review the submitted materials to determine that the applicant’s enrollee literature adequately discloses provisions, limitations and conditions of benefits available.

 (c)  If the Commissioner finds that the applicant meets the applicable standards in subsection (a) or (b), the Commissioner will notify the applicant and the Secretary of the determination.

 (d)  If the Commissioner determines that an applicant does not meet the applicable standards in subsection (a) or (b), the Commissioner will notify the applicant of the disapproval, in writing, specifying the reason for the disapproval. Within 30 days from the date of mailing of the notice to the preferred provider organization, the preferred provider organization may make written application to the Commissioner for a hearing. The hearing will be held within 30 days after receipt of the application. The procedure before the Commissioner will be under the adjudication procedure in 2 Pa.C.S. § §  501—508 and 701—704 (relating to the Administrative Agency Law). The preferred provider organization is entitled to judicial review as provided by statute.

Cross References

   This section cited in 31 Pa. Code §  152.22 (relating to fees); and 31 Pa. Code §  152.23 (relating to commencing operations).



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