(a) Complaints
System. Issuers must comply with this section; any requirements under a
Medicaid contract, subject to Government Code, Chapter 533; and any other
applicable law. The complaint system must provide reasonable procedures for the
resolution of oral and written complaints initiated by insureds or providers
concerning health care services, including a process for the notice and appeal
of complaints.
(1) If a complainant notifies
the issuer orally or in writing of a complaint, the issuer, not later than the
fifth business day after the date of the receipt of the complaint, shall send
to the complainant a letter acknowledging the date of receipt of the complaint
that includes a description of the organization's complaint procedures and time
frames. If the complaint is received orally, the issuer shall also enclose a
one-page complaint form. The one-page complaint form must prominently and
clearly state that the complaint form must be returned to the issuer for prompt
resolution of the complaint.
(A) The issuer
shall investigate each oral and written complaint received in accordance with
its policies and in compliance with this subchapter.
(B) Investigation and resolution of
complaints concerning emergencies or denials of continued stays for
hospitalization shall be concluded in accordance with the medical or dental
immediacy of the case and may not exceed one business day from receipt of the
complaint.
(C) For all other
complaints, the total time for acknowledgment, investigation, and resolution of
the complaint by the issuer may not exceed 30 calendar days after the date the
issuer receives the written complaint or one-page complaint form from the
complainant.
(D) After the issuer
has investigated a complaint, the issuer shall send a response letter to the
complainant explaining the issuer's resolution of the complaint within the time
frame as set forth in this section. The letter must include a statement of the
specific medical and contractual reasons for the resolution and the
specialization of any health care provider consulted. The response letter must
contain a full description of the process for appeal, including the time frames
for the appeal process and the time frames for the final decision on the
appeal.
(2) If the
complaint is not resolved to the satisfaction of the complainant, the issuer
shall provide an appeals process that includes the right of the complainant
either to appear in person before a complaint appeal panel at a location where
the insured normally receives health care services, unless another site is
agreed to by the complainant, or to address a written appeal to the complaint
appeal panel. The issuer shall complete the appeals process under this section
not later than the 30th calendar day after the date of the receipt of the
written request for appeal.
(A) The issuer
shall send an acknowledgment letter to the complainant not later than the fifth
business day after the date of receipt of the written request for
appeal.
(B) The issuer shall
appoint members to the complaint appeal panel, which shall advise the issuer on
the resolution of the dispute. The complaint appeal panel shall be composed of
equal numbers of issuer staff, physicians or other providers, and insureds.
Each member on the complaint appeal panel must not have been previously
involved in the disputed decision. The health care providers must have
experience in the area of care that is in dispute and must be independent of
any health care provider who made any prior determination. If specialty care is
in dispute, the appeal panel must include a person who is a specialist in the
field, or related field, of care to which the appeal relates. Panel members
that are insureds may not be employees of the issuer.
(C) Not later than the fifth business day
before the scheduled meeting of the panel, unless the complainant agrees
otherwise, the issuer shall provide to the complainant or the complainant's
designated representative:
(i) any
documentation to be presented to the panel by the issuer staff;
(ii) the specialization of any health care
providers consulted during the investigation; and
(iii) the name and affiliation of each issuer
representative on the panel.
(D) The complainant, or designated
representative if the insured is a minor or disabled, is entitled to:
(i) appear in person before the complaint
appeal panel;
(ii) present
alternative expert testimony; and
(iii) request the presence of and question
any person responsible for making the prior determination that resulted in the
appeal.
