Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-33 - HEALTH MAINTENANCE ORGANIZATIONS
Rule 120-2-33-.09 - Complaint System

Universal Citation: GA Rules and Regs r 120-2-33-.09

Current through Rules and Regulations filed through September 23, 2024

(1) Each HMO shall establish and maintain a complaint system to provide adequate and reasonable procedures for expeditious resolution of complaints made by enrollees concerning any matter related to any provision of such organization's health services, including, but not limited to, claims regarding the scope of coverage for health services, denials, cancellations, terminations or renewals of enrollee coverage, and the quality of health maintenance services rendered.

(2) The complaint system shall be organized in a manner that provides meaningful procedures for hearing and resolving complaints by enrollees. These procedures shall be fully set forth in group contracts, certificates and individual policies. The complaint system must be established and approved by the HMO's board of directors. Such complaint system shall include, but not be limited to:

(a) a definition of a legitimate complaint;

(b) details on how, when, where and with whom an enrollee is to file a complaint;

(c) appeals mechanisms and processes;

(d) the responsibilities of the various levels of the complaint system and the HMO staff;

(e) a written description of the process for timely review and disposition of all complaints; and

(f) a written policy about the reasonable time period for resolving complaints.

(3) These procedures shall also include any complaint submitted to the HMO by the Department or the Department of Human Resources as may be received by either Department from enrollees.

(4) If a complaint is made to the Department or the Department of Human Resources, such Department shall provide a copy of such complaint to the HMO concerned. The HMO shall provide a written response to such complaint within ten (10) working days to the complainant, with copies of such response to the Department and the Department of Human Resources.

(5) Pursuant to O.C.G.A. Section 33-21-9, each HMO shall submit for prior approval by the Commissioner and the Commissioner of Human Resources, and thereafter maintain, a system for the resolution of complaints. Such complaint procedures shall be filed in duplicate with the Department and the Department of Human Resources. In addition, each HMO shall:

(a) submit to the Commissioner and the Commissioner of Human Resources for prior approval any amendments or proposed changes to the system by which complaints may be filed and reviewed;

(b) maintain records of each complaint filed with the HMO for a period of five (5) years, such record to include, but not be limited to:
1. a copy of the complaint and the date of its filing;

2. the date and outcome of all consultations, hearings and hearing findings;

3. the date and decisions of any appeal proceedings;

4. the date and proceedings of any litigation; and

5. all letters, documents or evidence submitted regarding the complaint.

(6) The HMO shall also work with the medical group, individual practice association, or physicians under contract to promote the operation of peer review mechanisms internal to those provider groups.

(7) All enrollees who file written complaints shall first exhaust the complaint system available under the HMO. The complaint may then be investigated by the Commissioner or the Commissioner of Human Resources. The decision whether to investigate any complaint shall be at the discretion of the Commissioner or the Commissioner of Human Resources.

O.C.G.A. Secs. 33-2-9, Ch. 33-21.

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