34 Pa. Code § 127.455 – Requests for UR—conflicts of interest.

(a) A URO shall be deemed to have a conflict of interest and shall return a request for UR to the Bureau for reassignment if one or more of the following exist:
1. (1) The URO has a previous involvement with the patient or with the provider under review, regarding the same underlying claim.
2. (2) The URO has performed precertification functions in the same matter.
3. (3) The URO has provided case management services in the same matter.
4. (4) The URO has provided vocational rehabilitation services in the same matter.
5. (5) The URO is owned by or has a contractual arrangement with any party subject to the review.
(b) A URO shall inform the reviewer assigned to perform UR of the reviewer’s obligation to notify the URO of any potential or realized conflicts arising under § 127.468 (relating to duties of reviewers—conflict of interest).

Source

The provisions of this § 127.455 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222314).

Cross References

This section cited in 34 Pa. Code § 127.454 (relating to initial requests for UR—reassignment).