Missouri Code of State Regulations
Title 20 - DEPARTMENT OF COMMERCE AND INSURANCE
Division 100 - Insurer Conduct
Chapter 5 - Health Care Consumer Procedures
Section 20 CSR 100-5.010 - Notice Requirements of an Adverse Determination

(1) A written notification of an adverse determination shall be printed in clear legible type of at least twelve (12)-point font.

(2) The notice shall explain the principal reason for the adverse determination in language easily understood by a person with an eighth grade reading level. A health carrier may determine the reading level of a notice without including medical terminology which describes an enrollee's medical condition, proper names, telephone numbers and addresses.

(3) The notice shall explain how an enrollee initiates a grievance review. If an enrollee is eligible for an expedited review pursuant to section 376.1389, RSMo, then the notice shall explain how an enrollee initiates an expedited review.

(4) The notice shall explain how an enrollee as defined in section 376.1350(14), RSMo initiates a grievance review of the adverse determination with the director. The notice shall explain that an enrollee may file a grievance with the director at any time. The notice shall also list the Consumer Affairs Division's toll-free telephone number.

(5) The notice shall describe how the enrollee can request a written statement of the clinical rationale and clinical review criteria used to make the adverse determination.

(6) If the Health Care Financing Administration's Medicare or Medicaid plans have notification requirements for grievance procedures, those notification requirements shall satisfy the requirements of this rule for notification of enrollees in those plans if the notices comply with all Missouri statutory requirements.

(7) The notice shall inform enrollees that they have a right to have a relative, friend, lawyer, the department or other representative help them with a grievance.