40-3228. Grievance procedures; minimum requirements.
40-3228
40-3228. Grievance procedures; minimum requirements.A health maintenance organization shall provide in itscertificate of coverage the procedures for resolving enrollee grievances. At aminimum, the certificate of coverage shall include the following provisions:
(a) The definition of a grievance;
(b) how, where and to whom the enrollee should file such enrollee'sgrievance; and
(c) that upon receiving notification of a grievance related for payment of abill for medical services, the health maintenance organization shall:
(1) Acknowledge receipt of the grievance in writing within 10 working daysunless it is resolved within that period of time;
(2) conduct a complete investigation of the grievance within 20 working daysafter receipt of a grievance, unless the investigation cannot be completedwithin this period of time. If the investigation cannot be completed within 20working days after receipt of a grievance, the enrollee shall be notified inwriting within 30 working days time, and every 30 working days after that,until the investigation is completed. The notice shall state the reasons forwhich additional time is needed for the investigation;
(3) have within five working days after the investigation is completed,someone not involved in the circumstances giving rise to the grievance or itsinvestigation decide upon the appropriate resolution of the grievance andnotify the enrollee in writing of the decision of the health maintenanceorganization regarding the grievance and of any right to appeal. The noticeshall explain the resolution of the grievance and any right to appeal. Thenotice shall explain the resolution of the grievance in terms which are clearand specific; and
(4) notify, if the health maintenance organization has established agrievance advisory panel, the enrollee of the enrollee's right to request thegrievance advisory panel to review the decision of the health maintenanceorganization. This notice shall indicate that the grievance advisory panel isnot obligated to conduct the review. This provision shall also state how,where and when the enrollee should make such enrollee's request for thisreview.
History: L. 1996, ch. 169, § 12; July 1.