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2000 SESSION

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HB 726 Managed care health insurance plans.

Introduced by: John H. Rust, Jr. | all patrons    ...    notes | add to my profiles

SUMMARY AS PASSED: (all summaries)

Managed care health insurance plans; Office of Managed Care Ombudsman; External Review Process. Clarifies provisions of the 1999 omnibus health insurance legislation regarding the Managed Care Ombudsman and the external review process. The amendments make clear that legislation created an Office of Managed Care Ombudsman, rather than a single position. Other amendments regarding the External Review Process (i) establish the threshold for the External Review Process at $300 in out-of-pocket costs to the covered person if the adverse decision is not reversed; (ii) increase to 30 days the time period for the external reviewer to complete its review; (iii) increase the other time periods for actions by the parties related to the review and the Bureau; (iv) make a utilization review entity's failure to comply with the Commissioner's written ruling subject to sanctions as a knowing and willful violation of the statute; (v) provide that fees paid by utilization review entities are paid to the Bureau's maintenance fund; (vi) establish sanctions against utilization review entities who fail to pay the fee within a reasonable time; (vii) provide that, before entering in to contracts with an impartial health entity to conduct external reviews, the Bureau shall determine that the entity possesses the necessary credentials and is otherwise qualified to conduct the review; (viii) limits access to the external review process to individuals covered under a contract issued in this Commonwealth; and (ix) clarify that the Commissioner of Insurance is to affirm recommendations of the independent review entity unless they are arbitrary, capricious or beyond the review entity's authority. The bill also makes a number of housekeeping amendments to other provisions of the 1999 legislation.


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