Current through Register Vol. XLI, No. 38, September 20, 2024
6.1. An issuer shall
establish written procedures for a standard review of a grievance that does not
involve an adverse determination.
6.2.
The procedures shall permit a covered person to file a grievance that does not
involve an adverse determination with the issuer under this section.
6.2.a. A covered person does not have the right to
attend, or to have a representative in attendance at the standard review, but the
covered person is entitled to submit written material for the person or persons
designated by the carrier pursuant to subsection 6.3 to consider when conducting the
review.
6.2.b.. The issuer shall make
the provisions of subdivision 6.2.a known to the covered person within three working
days after the date of receiving the grievance.
6.3. Upon receipt of the grievance, an issuer
shall designate a person or persons to conduct the standard review of the grievance.
6.3.a. The issuer may not designate the same
person or persons to conduct the standard review of the grievance that denied the
claim or handled the matter that is the subject of the grievance.
6.3.b. The issuer shall provide the covered person
with the name, address and telephone number of a person designated to coordinate the
standard review on behalf of the issuer.
6.4. The issuer shall notify in writing the
covered person of the decision within twenty working days after the date of receipt
of the request for a standard review of a grievance filed pursuant to subsection
6.2.
6.4.a. Subject to subdivision 6.4.b, if, due
to circumstances beyond the issuer's control, the issuer cannot make a decision and
notify the covered person pursuant to subsection 6.4 within twenty working days, the
issuer may take up to an additional ten working days to issue a written
decision.
6.4.b. An issuer may extend
the time for making and notifying the covered person in accordance with subdivision
6.4.a, if, on or before the twentieth working day after the date of receiving the
request for a standard review of a grievance, the issuer provides written notice to
the covered person of the extension and the reasons for the delay.
6.5. The written decision issued
pursuant to subsection 6.4 shall contain:
6.5.a.
The titles and qualifying credentials of the person or persons participating in the
standard review process (the reviewers);
6.5.b. A statement of the reviewers' understanding
of the covered person's grievance;
6.5.c. The reviewer's decision in clear terms and
the contract basis in sufficient detail for the covered person to respond further to
the issuer's position;
6.5.d. A
reference to the evidence or documentation used as the basis for the decision;
and
6.5.e. Notice of the covered
person's right, at any time to contact the Commissioner's office, including the
telephone number and address of the Commissioner's office.
