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of the Commonwealth of Pennsylvania

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    Bureau of Health Coverage Access, Administration, and Appeals

    Forms and Instructions

    ​Forms & Instructions

    ​Form
    		​
    ​Act 146 Templates & Forms

    ​Disclosure Language 2136(c)
    Initial ABD Notice 2164.2(a)(1)
    Final ABD Notice 2164.2(a)(2)
    Eligibility for External Review Notice 2164.5
    Independent External Review Request Form
    Physician Certification Form

    ​Annual Report
    		 ​2024 Annual Report Instructions
    2024 Annual Report Form

    2023 Annual Report Instructions
    2023 Annual Report Form

    Notes: Annual reports are due April 30.
    Provider Directory Form
    ​Certified Review Entity (CRE) Application
    		​Certified Review Entity (CRE) Application
    ​ERO Assignment
    		​ERO Assignment Letter Template

    Notes: “External Grievance Process for MA MCOs – Updated", MA MCOs are responsible for providing notice of the documents provided and the member's rights with respect to the external review process. A word version of the template letter (included as Appendix B in the technical advisory), which is designed to meet the Department's expectations for member notification, is provided here for use by MCOs.  MCOs may use corporate letterhead as needed and should include the relevant information indicated in the sections identified in bolded brackets.​
    Quarterly Report
    		2024 Quarterly Report Instructions
    2024 Quarterly Report Form​

    ​​2023 Quarterly Report Instructions
    2023 Quarterly Report Form

    Notes: Quarterly reports are due May 15 (Quarter 1), August 15 (Quarter 2), November 15 (Quarter 3), and February 15 (Quarter 4).
    ​Quest Analytics Network Adequacy Template
    		​PY23 Network Adequacy Template
    PY24 Network Adequacy Template
     
    Note:  This template is only to be used for networks that are submitted to Quest Analytics.
    ​Preferred Provider Organization (PPO)
    		​PPO Instructions
    PPO Application

    Notes:  PPOs generally include entities who have entered into arrangements with health care providers either to establish a provider network or to provide health care services for the PPO's enrollees. PPO health insurance policies provide incentives, such as a higher level of coverage, to enrollees when those enrollees use network providers.

    If you are applying for a Gatekeeper PPO (GPPO) or submitting a GPPO product filing, you must address the requirements of the Pennsylvania Quality Health Care Accountability and Protection Act (Act 68 of 1998) and related regulations in your application and policy forms.
    ​Provider Initiated Grievance Enrollee Consent
    		​Provider Initiated Grievance Enrollee Consent Requirements
    Provider Initiated Grievance Enrollee Consent Form (Sample)

    Notes: This form was developed to assist in resolving disputes regarding what constitutes valid enrollee written consent for a health care provider to initiate a grievance with a managed care plan on behalf of the enrollee.  Use of this form is strictly optional however if a provider and enrollee follow its format, the enrollee consent will be deemed by the Department to be compliant with 28 Pa. Code 9706 and valid.