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INSURANCE DEPARTMENT

Certification as an Independent Review Organization; Long-Term Care Benefit Trigger Determinations; Notice 2013-07

[43 Pa.B. 3314]
[Saturday, June 15, 2013]

 The act of July 9, 2010 (P.L. 362, No. 51) (Act 51) added a provision to the Commonwealth's long-term care insurance laws granting a right to appeal an insurer's determination that a benefit trigger is not met. See section 1111.1 of The Insurance Company Law of 1921 (act) (40 P. S. § 991.1111a). Act 51 also added definitions of ''benefit trigger'' and ''independent review organization'' to section 1103 of the act (40 P. S. § 991.1103).

 Under this act, an entity must be certified by the Insurance Department (Department) to perform an independent review of benefit trigger determinations. To be certified, an independent review organization (IRO) must: (a) be certified as an IRO in another state, if the other state requires the IRO to meet substantially similar qualifications as those established by the National Association of Insurance Commissioners; or (b) be certified or approved by the Department. To maintain certification, the IRO shall comply with the requirements of the Act 51 amendments to the long-term care insurance laws and its representations in its application to the Commonwealth or any other state by which it is certified.

 The following organizations have been approved, as of May 31, 2013, by the Department to perform independent reviews of long-term care benefit trigger determinations:

Clinix Healthcare
3492 Snouffer Road, Suite 200
Columbus, OH 43235
Telephone: (800) 854-8206
Fax: (614) 889-2148
Contact: Olga Magyar

IMX Medical Management Services
Two Bala Plaza, Suite 600
P. O. Box 557
Bala Cynwyd, PA 19004-0557
Telephone: (610) 667-4463, Ext. 206
Fax: (610) 667-4764
Contact: Darcy Saunders

LTCI Independent Eligibility Review Specialists, LLC
1636 North Cedar Crest Boulevard, Suite 107
Allentown, PA 18104
Telephone: (800) 878-9579
Fax: (484) 661-4757
Contact: Stephen R. La Pierre

National Medical Reviews, Inc.
260 Knowles Avenue, Suite 330
Southampton, PA 18966
Telephone: (215) 352-7800
Fax: (215) 352-7801
Contact: Elaine Nace

MAXIMUS Federal Services, Inc.
11419 Sunset Hills Road
Reston, VA 20190-5207
Telephone: (703) 251-8500
Fax: (703) 251-8240
Contact: David Sherman

Permedion, Inc.
350 Worthington Road, Suite H
Westerville, OH 43082
Phone: (614) 895-9900
Fax: (614) 839-2628
Contact: Seana Ferris

Reviews will be conducted at the following location:

MAXIMUS Federal Services, Inc.
50 Square Drive, Suite 210
Victor, NY 14564
Telephone: (585) 425-5200
Fax: (585) 425-5290

 Questions regarding this notice may be directed to Carolyn M. Morris, Director, Bureau of Consumer Services at (717) 783-9862 or camorris@state.pa.us.

MICHAEL F. CONSEDINE, 
Insurance Commissioner

[Pa.B. Doc. No. 13-1100. Filed for public inspection June 14, 2013, 9:00 a.m.]



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