Section 2161. Internal Grievance Process.--(a) An MA or CHIP managed care plan shall establish and maintain an internal grievance process with one level of review and an expedited internal grievance process by which an enrollee, an enrollee's authorized representative or a health care provider, with the written consent of the enrollee or the enrollee's authorized representative, shall be able to file a written grievance regarding the denial of payment for a health care service. An enrollee or an enrollee's authorized representative who consents to the filing of a grievance by a health care provider under this section may not file a separate grievance.
(b) The internal grievance process shall consist of a review that includes all of the following:
(1) A review by three or more persons selected by the MA or CHIP managed care plan who did not previously participate in the decision to deny payment for the health care service.
(2) A written notification to the enrollee or the enrollee's authorized representative of the decision of the review committee within thirty (30) days of receipt of the grievance unless the time frame for deciding the grievance has been extended by up to fourteen (14) days at the request of the enrollee or the enrollee's authorized representative.
(3) The notice shall include the basis and clinical rationale for the decision and the procedure to file a request for an external review.
(c) A review conducted under this section shall include a licensed physician or, where appropriate, a licensed psychologist or licensed dentist, in the same or similar specialty that typically manages or consults on the health care service.
(1) ((1) deleted by amendment).
(2) ((2) deleted by amendment).
(3) ((3) deleted by amendment).
(4) ((4) deleted by amendment).
(d) ((d) deleted by amendment).
(e) Should the enrollee's life, health or ability to regain maximum function be in jeopardy, an expedited internal grievance process shall be available which shall include a requirement that a decision with appropriate notification to the enrollee, enrollee's authorized representative and health care provider be made within forty-eight (48) hours of the filing of the expedited grievance.
(2161 amended Nov. 3, 2022, P.L.2068, No.146)