28 Pa. Code §9.705(c)(1)(vi)

(vi) The plan shall notify the enrollee in writing of the decision of the initial review committee within 5 business days of the committee’s decision. The notice to the enrollee and the enrollee’s representative shall include the basis for the decision and the procedures to file a request for a second level review of the decision of the initial review committee including:

(A) A statement of the issue reviewed by the first level review committee.

(B) The specific reasons for the decision.

(C) References to the specific plan provisions on which the decision is based.

(D) If an internal rule, guideline, protocol, or other similar criterion was relied on in making the decision, either the specific rule, guideline, protocol or criterion, or instructions on how to obtain the internal rule, guideline, protocol or criterion.

(E) An explanation of how to request a second level review of the decision of the initial review committee.

(F) The time frames for requesting a second level review, if any. See § 9.702(d)(1) (relating to complaints and grievances).