§ 69.55. Criteria for Department approval of a PRO.
(a) A PRO shall apply in writing to the Commissioner for approval to contract with an insurer to provide peer review services in accordance with the act and this chapter. If the application is disapproved, the PRO may appeal the disapproval to the Commissioner. If the Commissioner determines that reasonable grounds exist to review the disapproval, the Commissioner may schedule a hearing to review the determination. The hearing shall be conducted in accordance with 2 Pa.C.S. § § 501—508 and 701—704 (relating to the Administrative Agency Law).
(b) A PRO applicant shall include in its written application the following information:
(1) A Certification of Independence. A PRO may not be owned by a Pennsylvania-licensed insurer. While a PRO may be organized by one or more insurers, that PRO may not review the claims of those insurers, may not be a subsidiary or affiliate of those insurers’ corporate structure and none of the PRO’s officers or directors may have a direct financial interest in the insurers. PRO personnel may not review services provided to an insured by an institution or agency in which they have financial interest.
(2) A description of previous experience as a PRO and the length of time in operation.
(3) A certification that reviews are conducted by medical personnel licensed in this Commonwealth.
(4) A compensation policy. A PRO shall charge for its service on a flat fee or hourly rate basis. A PRO may not charge for services on a percentage or contingency fee basis.
(5) A quality assessment of the PRO’s review services, including examples of the PRO’s review procedures.
(6) A policy statement on the preservation of the confidentiality of medical records.
(7) A certification that the PRO will operate and provide services in accordance with § § 69.51—69.54 and this section.
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