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 100-5.020 - Grievance Review Procedures
Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule sets forth with greater specificity the procedures by which the department will process a grievance concerning an adverse determination by a health carrier or its designee for a health plan that has a managed care component. This rule is promulgated pursuant to section 376.1399, RSMo, and implements section 376.1387, RSMo.
(1) As used in this rule, "division" means the Consumer Affairs Division.
(2) As used in this rule, "enrollee's representative" or "representative" means-
(3) When a health carrier, as defined by section 376.1350(22), RSMo, or their designee utilization review organization issues an adverse determination, as defined by section 376.1350(1), RSMo, to an enrollee in a health plan that has a managed care component, the enrollee or his/her representative may file a grievance with the director without exhausting all remedies available under the carrier's grievance process. Medicaid participants also may use the division's grievance process in an effort to resolve an adverse determination; however, the director may not have the authority to issue an order in such cases.
(4) A health carrier or plan sponsor also may file a grievance with the director concerning an adverse determination.
(5) A grievance will be processed by the division as any other consumer complaint. The division will assign the grievance a file number. The division will send an inquiry to the health carrier (or party) which is complained against requesting the health carrier (or party) to respond in writing with their position and all supporting documentation concerning the matter grieved. The division will attempt to resolve the issue with the health carrier (or party).
(6) If the director determines a grievance is unresolved after completion of the division's consumer complaint process, the director shall refer the unresolved grievance to an independent review organization (IRO). An unresolved grievance shall include a difference of opinion between a treating health care professional and the health carrier concerning the medical necessity, appropriateness, health care setting, level of care, or effectiveness of a health care service.
(7) The director shall seek the services of an IRO(s) by competitive bid pursuant to Chapter 34, RSMo. Any IRO selected through the competitive bid process shall be accredited by a nationally-recognized private accrediting organization. The department shall maintain a current list of IROs under contract with the department on its website.
(8) An IRO shall maintain written policies and procedures governing all aspects of the external review process that include a quality assurance mechanism that, at a minimum-
(9) An IRO may not own or control, be a subsidiary of, or in any way be owned or controlled by, or exercise control with a health carrier; a national, state, or local trade association of health carriers; or a national, state, or local trade association of health care providers. Neither the IRO selected to conduct the external review nor the clinical peer assigned by the IRO to conduct the external review may have a material, professional, familial, or financial conflict of interest with any of the following:
(10) The director will provide the IRO and the enrollee, enrollee's representative, or health carrier copies of all medical records and any other relevant documents which the division has received from any party. The enrollee, enrollee's representative, and health carrier may review all the information submitted to the IRO for consideration.
(11) The enrollee, enrollee's representative, or health carrier may also submit additional information to the division which the division shall forward to the IRO. All additional information must be received by the division. If an enrollee, enrollee's representative, or health carrier has information which contradicts information already provided the IRO, they should provide it as additional information. All additional information should be received by the division within fifteen (15) working days from the date the division mailed that party copies of the information provided the IRO. An envelope's postmark shall determine the date of mailing. Information may be submitted to the division by means other than mail if it is in writing, typeset, or easily transferred into typeset by the division's technology and a date of transmission is easily determined by the division. Any additional information submitted by the enrollee or the enrollee's representative shall be reviewed by the IRO when conducting the external review. At the director's discretion, additional information which is received past the fifteen (15-) working-day deadline may be submitted to the IRO.
(12) The IRO shall request from the division any additional information it wants. The division shall gather the requested information from an enrollee, enrollee's representative, or health carrier or other appropriate entity and provide it to the IRO. If the division is unable to obtain the requested information, the IRO shall base its opinion on the information already provided.
(13) Within twenty (20) calendar days of the receipt of the request for external review, the IRO shall submit to the director its opinion of the issues reviewed. Under exceptional circumstances, if the IRO requires additional time to complete its review, it should request in writing from the director an extension in the time to process the review, not to exceed five (5) calendar days. Such a request should include the reasons for the request and a specific time at which the review is expected to be complete.
(14) After the director receives the IRO's opinion, the director shall issue a decision which shall be binding upon the enrollee and the health carrier. The director's decision shall be in writing and must be provided to the enrollee and health carrier within twenty-five (25) calendar days of receiving the IRO's opinion. In no event shall the time between the date the IRO receives the request for external review and the date the enrollee and the health carrier are notified of the director's decision be longer than forty-five (45) days.
(15) An enrollee or enrollee's representative or health carrier may request an expedited external review if the adverse determination-
(16) As expeditiously as possible after receipt of the request for expedited external review by the IRO, the IRO must issue its opinion as to whether the adverse determination should be upheld or reversed and submit its opinion to the director. As expeditiously as possible, but within no more than seventy-two (72) hours after the receipt of the request for expedited external review by the IRO, the director shall issue notice to the enrollee and the health carrier of the director's determination and may issue a decision to uphold or reverse the adverse determination. If the notice is not in writing, the director must provide the written decision within forty-eight (48) hours after the date of the notice of the determination.
(17) If a request for external review of an adverse determination involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, the following additional requirements must be met:
*Original authority: 374.045, RSMo 1967, amended 1993, 1995, 2008; 376.1387, RSMo 1997; and 376.1399, RSMo 1997, amended 1997, 2007.