Section 2154. Medical policies and clinical review criteria.
(a) Medical policies.--
(1) An insurer or MA or CHIP managed care plan shall make available its current medical policies through the insurer's or MA or CHIP managed care plan's publicly accessible Internet website and provider portal.
(2) Each medical policy developed by an insurer or MA or CHIP managed care plan shall identify the clinical review criteria used in the policy's development. The insurer or MA or CHIP managed care plan shall identify any third-party licensure restrictions preventing disclosure of all or part of clinical review criteria.
(3) An insurer or MA or CHIP managed care plan shall review each adopted medical policy on at least an annual basis.
(4) (i) An insurer or MA or CHIP managed care plan shall notify providers of a change to a medical policy as follows:
(A) In the case of a policy change due to a change in Federal or State law or binding agency guidance, when the required implementation date of that policy change is sooner than 30 days, as soon as practicable.
(B) In the case of a change to a medical policy that modifies, eliminates or suspends either clinical or administrative criteria and that directly results in less restrictive coverage of a given service, within 30 days after application of the change.
(C) In cases other than in clauses (A) and (B), at least 30 days prior to application of the change.
(ii) A notification of change may be provided through reasonable means, including posting of an updated and dated medical policy reflecting the change.
(b) Clinical review criteria.--
(1) Clinical review criteria adopted by an insurer or MA or CHIP managed care plan shall, at the time of medical policy development or review:
(i) Be based on applicable nationally recognized medical standards.
(ii) Be consistent with applicable governmental guidelines.
(iii) Provide for the delivery of a health care service in a clinically appropriate type, frequency and setting and for a clinically appropriate duration.
(iv) Reflect the current medical and scientific evidence regarding emerging procedures, clinical guidelines and best practices as articulated in independent, peer-reviewed medical literature.
(2) Nothing in this act shall require an insurer or MA or CHIP managed care plan to provide coverage for a health care service to a covered person or enrollee that is otherwise excluded from coverage under a health insurance policy or an agreement with the Department of Human Services.
(2154 added Nov. 3, 2022, P.L.2068, No.146)