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§ 991.2142. Appeal of complaint or administrative denial

Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: January 1, 2024

Purdon's Pennsylvania Statutes and Consolidated Statutes
Title 40 P.S. Insurance (Refs & Annos)
Chapter 2. Insurance Companies (Refs & Annos)
Article XXI. Quality Health Care Accountability and Protection (Refs & Annos)
(g) Complaints
Effective: January 1, 2024
40 P.S. § 991.2142
§ 991.2142. Appeal of complaint or administrative denial
Currentness
(a) For an appeal of a complaint:
(1) If the subject of the complaint is listed in section 2141.1(b)(6),1 an enrollee or the enrollee's authorized representative shall have fifteen (15) days from receipt of the notice of decision to appeal the decision to the department.
(2) If a second level review was completed, a covered person or an enrollee, or the covered person's or enrollee's authorized representative, shall have fifteen (15) days from receipt of the notice of the decision from the second level review committee to appeal the decision to the department.
(b) For an appeal of an administrative denial:
(1) A covered person or covered person's authorized representative may appeal a decision about the coverage, operations or management policies of an insurer, other than decisions that are adverse benefit determinations.
(2) A covered person or covered person's authorized representative shall have fifteen (15) days from receipt of the notice of a decision conducted under section 21642 on an administrative denial to appeal the decision to the department.
(b.1) All records from the internal process for the complaint or administrative denial shall be transmitted to the department in the manner prescribed. The covered person or enrollee, the covered person's or enrollee's authorized representative, the health care provider or the insurer or MA or CHIP managed care plan may submit additional materials related to the complaint or administrative denial.
(c) The covered person or enrollee may be represented by an attorney or other individual before the department.
(d) The department shall determine whether a violation of this article has occurred and may impose any penalties authorized by this article.

Credits

1921, May 17, P.L. 682, No. 284, § 2142, added 1998, June 17, P.L. 464, No. 68, § 1, effective Jan. 1, 1999. Amended 2022, Nov. 3, P.L. 2068, No. 146, § 4, effective Jan. 1, 2024.

Footnotes

1
40 P.S. § 991.2141a.
2
40 P.S. § 991.2164.
40 P.S. § 991.2142, PA ST 40 P.S. § 991.2142
Current through Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
End of Document