376.1387. Appeals of grievances determined by the director.
Appeals of grievances determined by the director.
376.1387. 1. The director shall resolve any grievance regarding anadverse determination as to covered services appealed by an enrollee orhealth carrier or plan sponsor through any means not specificallyprohibited by law but if the grievance is unresolved by the director thenit shall be resolved by referral of such grievance to an independent revieworganization. The director shall establish the qualifications for suchreview organizations(s) and shall seek the services of such organization(s)by competitive bid pursuant to chapter 34, RSMo. The director shall enterinto contracts with such organization(s) as deemed necessary to conduct theadverse determination appeals process set forth in this section. Anyrequest for an adverse determination appeal shall be assigned on arotational basis. The organization's decision as to the resolution of thegrievance shall be based upon a review of the written record before it.The grievance and resolution of such grievance shall not be considered acontested case within the meaning of section 536.010, RSMo, but theresolution of such grievance by the panel shall be considered a finalagency decision within the director's discretion, binding upon the enrolleeand health carrier, and subject to judicial review if:
(1) Action for such review is filed within thirty days of the finalagency decision; and
(2) Judicial review is limited to the record before the director; and
(3) The enrollee and health carrier are deemed real parties ininterest; and
(4) The scope of judicial review extends only to a determination ofwhether the action of the director is unconstitutional, unlawful,unreasonable, arbitrary, or capricious or involves an abuse of discretionor is in excess of the statutory authority or jurisdiction of the director.
2. Nothing in this section is intended to restrict the director'sauthority to investigate and resolve any complaint against a health carrierthat does not constitute a grievance within the meaning of section376.1350.
3. Any grievance involving coverage provided pursuant to a Medicaidprogram, however, shall be resolved in accordance with the rules andprocedures established for the Medicaid program.
(L. 1997 H.B. 335)