Current through Register Vol. 42, No. 11, August 30, 2024
(1) A health
maintenance organization shall have an enrollee complaint process, to include
an informal review, a formal review, and an expedited formal review for the
prompt resolution of complaints regarding such things as (a) the availability,
delivery, or quality of health care service, (b) claims payment, handling or
reimbursement for health care services, (c) matters pertaining to the
administrative or contractual relationship, or both, between an enrollee and
the health maintenance organization. Issues which can be resolved by telephone
to the enrollee's satisfaction shall not be classified as a complaint.
(a) Inquiry means normal business operations
conducted verbally or in writing between the health maintenance organization
and enrollees. These inquiries may include such things as requests for
identification cards, clarification of benefits, and address changes. Inquiries
will be resolved to the enrollee's satisfaction and within a time frame that is
acceptable to the enrollee. Inquiries shall be tracked and trended by issue
involved to allow the health maintenance organization to identify systemic or
commonly occurring areas.
(b)
Informal Complaint means those issues that are not resolved to the members
satisfaction at the inquiry level or for which the enrollee requests a written
response. Informal complaints will be tracked in accordance with Chapter
420-5-6-.08(4).
(c) Formal complaint means the subsequent
written expression by or on behalf of an enrollee regarding the resolution of
an informal complaint. Discussions between a provider and the health
maintenance organization during the utilization review process do not
constitute a formal complaint. Authorization from the enrollee shall not be
required for the provider's involvement in the utilization review process.
A provider may act on behalf of the enrollee in the formal
complaint process if the physician certifies in writing that the enrollee is
unable to act on his or her own behalf due to illness or disability. A family
member, friend of the enrollee, or any other person may act on behalf of the
enrollee after written notification to the health maintenance organization by
the enrollee. A provider may also access the provider dispute mechanism as set
forth in the provider contract without written authorization of the
enrollee.
(d) Expedited
Formal Complaint means a verbal or written request by the enrollee or the
provider regarding an adverse medical necessity decision in the utilization
review process. The request must describe the medical urgency of the situation
to justify the expedited process.
(2) A health maintenance organization shall
have a designated Alabama phone number and address for the receipt of enrollee
complaints. A staff member shall be designated to oversee the complaint
process.
(3) The complaint process,
including the informal, formal, and expedited processes, must be fully
described in enrollee contracts and enrollee handbooks.
(4) All informal, formal, and expedited
complaints must be entered into a written or backed-up automated log.
(a) The log should include the nature of the
complaint, date received, date action taken by the plan and date enrollee
notified.
(5) The health
maintenance organization shall have an informal complaint process.
(a) A decision regarding an informal
complaint and the mailing of notice to the enrollee must take place within 45
calendar days of receipt of the informal complaint. The notification must
detail the outcome of the informal complaint and in the case of an adverse
outcome, advising of the right to file a formal complaint.
(b) A formal complaint shall be filed within
twelve months of the health maintenance organization's receipt of the informal
complaint. However, extenuating circumstances will be considered by the health
maintenance organization.
(6) The health maintenance organization shall
have a formal complaint process.
(a) The
health maintenance organization shall maintain a record which demonstrates the
health maintenance organization has considered all aspects of the enrollee's
complaint.
(b) The enrollee and any
other party of interest may provide pertinent data. The enrollee will be
notified in writing of this right.
(c) At the request of the enrollee, the
health maintenance organization shall appoint a member of its staff who has no
direct involvement in the case to assist the enrollee. The enrollee shall be
notified in writing of this right.
(d) The enrollee shall have the right to
appear before the formal complaint committee.
(e) The medical director for the health
maintenance organization shall determine the need to consult qualified
specialty consultants during the formal review process.
(f) A review of the formal complaint shall be
conducted by a committee of one or more individuals, who may be employees of
the health maintenance organization. Committee members representing the health
maintenance organization shall be employed by the health maintenance
organization and be familiar with the policies and procedures of the Alabama
health maintenance organization.
(g) The formal complaint committee shall
render a decision within 30 calendar days of receipt of the written formal
complaint. The enrollee must receive written notification regarding the
resolution of the formal complaint within 5 working days of the decision
detailing the outcome of the formal complaint. The notification shall provide
notice that the enrollee may appeal to the state complaint committee through
the
State Health Officer or the Commissioner of the Alabama
Department of Insurance.
(h) The formal complaint committee will
consider enrollee or provider requests for an expedited formal complaint review
of an adverse medical necessity decision in the utilization review process. The
request must support the fact that a standard response time could seriously
jeopardize the life or health of the enrollee or the enrollee's ability to
regain maximum function. If justified for an expedited review, the committee
shall render a decision within a time period that accommodates the clinical
urgency of the situation. However, a decision must be made no later than three
working days of receipt of the request. The provider's office will be notified
either electronically or in writing on the day of the decision or on the next
business day if the provider's office is closed, followed by written
notification to the provider and enrollee within three working days of the
decision. The notification shall provide notice that the enrollee may appeal to
the state complaint committee through the State Health Officer or the
Commissioner of the Alabama Department of Insurance.
(7) If the health maintenance organization
delegates the receipt, investigation, decision-making, or communication piece
of the complaint process to a contracted provider, the provider contract and
health maintenance organization policy and procedure must adequately describe
the delegated functions, required reporting to the health maintenance
organization, and the health maintenance organization's ultimate responsibility
for the process.
(8) The health
maintenance organization shall maintain records of all complaints and shall
include in quarterly and annual reports to the Department the total number of
complaints received and the number of complaints unresolved.
(9) If a complaint concerns any provider with
whom a health maintenance organization contracts, the Department may make an
examination concerning health care services of the health maintenance
organization and provider.
Author: Department of Public
Health
Statutory Authority:
Code of Ala.
1975, §§
22-2-2(6),
et
seq., 22-21-20,
et
seq., 27-21A-1,
et
seq.
