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Managed Care Technical Advisories:
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Time Frames for Acknowledging the Receipt of Complaints and Grievances by a Managed Care Plan
(Note: Published in Pennsylvania Bulletin (09/22/2007)
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Notification of Enrollees Affected by the Termination of Non-Primary Care Providers/Specialists by a Managed Care Plan
(Note: Published in Pennsylvania Bulletin (05/06/2006)
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Providing Credentialing and Credentialing Standards as related to:
(Note: Published in Pennsylvania Bulletin (02/11/2006)
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Instruction for Appeal Transmittal Letters
(Note: Published in Pennsylvania Bulletin (12/03/2005)
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Communicating the UR Decision
(Note: Published in Pennsylvania Bulletin (01/01/2005)
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UR Denial Contract Language
(Note: Published in Pennsylvania Bulletin (01/01/2005)
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Gatekeeper and Point-of-Service Plans
The Department of Health is experiencing increased interest by managed care organizations seeking to offer products that provide less than 80% plan coverage for out-of–network services.
Enrollees who contact the Bureau of Managed Care for assistance after receiving services from out-of-network providers are often unaware of the practice of provider balance billing and rarely understand the significant financial liability that can result from this practice. Most enrollees, when faced with significant balance bills explain that had they known how costly it would be to obtain services from an out-of-network provider, they would have obtained their services in-network.
The Department, in consultation with the Insurance Department, has developed the following technical assistance in an effort to protect enrollees from under-service and poor quality care and to ensure that members have full knowledge and understanding of the limited coverage they can expect when seeking care from out-of-network providers, including the impact of balance billing. Any managed care organization offering an HMO, point-of-service or gatekeeper PPO product that provides less than 80% plan coverage for out-of–network services, must provide the Department of Health with an updated provider network listing and an estimate of how much out-of-network usage by enrollees is anticipated. The managed care plan must also provide the Department with the information it intends to provide to enrollees explaining out-of-network coverage and the likely financial consequences of balance billing.
Technical Advisory
(Note: Published in Pennsylvania Bulletin (10/13/2004)
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Provider Initiated Grievance & Enrollee Consent Form
Please note: This form was developed in response to requests from managed care plans and health care providers in an attempt to resolve disputes about what constitutes valid enrollee written consent for a health care provider to initiate a grievance with a managed care plan on behalf of the enrollee.
Use of this form is strictly optional.
Technical Advisory
(Note: Published in Pennsylvania Bulletin (6/19/2004)
Enrollee Consent Form
(Note: Published in Pennsylvania Bulletin (6/24/2004)
Notice is hereby give that, pursuant to 28 Pa. Code §9603, the Department of Health, Bureau of Managed Care (the Department), is issuing the linked sample enrollee consent form for provider-initiated grievances. If a provider and enrollee follow its format, this consent form will be deemed by the Department to be compliant with 28 Pa. Code §9706, and constitute valid enrollee consent for the purpose of a provider grievance.
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