Minimum Qualifications
Physician shall possess an unrestricted license to practice medicine within the Commonwealth of Pennsylvania.
Physician shall be certified by the American Board of Medical Specialties or the American Osteopathic Association for his or her area of medical specialty and currently be in active clinical practice.
Physician must provide curriculum vitae to demonstrate knowledge and experience in their medical specialty if requested by the Department.
Role Description:
Physician must be able to receive medical records and other materials associated with the case electronically, by fax, or by mail.
Physician shall provide a written decision upholding or overturning the continuity of care denial based upon the definition of continuation of care that is in place at the time of the service was requested or received, the member's physical condition, medical records, the rationale and clinical information submitted by the member's provider, the rational for the denial of the continuity of care request, standards of medical practice for the member's condition, and other relevant materials provided by the insurer, the member or his physician.
Physician shall provide the Department with a written decision in a regular case review within 7 business days of receiving all the case materials.
If the Department requests an expedited review, Physician shall provide the Department with a written decision within 2 business days of receiving all the case materials.
Reimbursement for regular or expedited reviews shall be made based upon the total number of hours needed to review the case and submit the written decision to the Department.
The reviewing time per case shall not exceed three hours unless the Department pre-authorizes additional time.
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