A health maintenance organization shall provide in its certificate of coverage the
procedures for resolving enrollee grievances. At a minimum, the certificate of coverage shall include the following provisions:
(a) The definition of a grievance;
(b) how, where and to whom the enrollee should file such enrollee's grievance; and
(c) that upon receiving notification of a grievance related for payment of a bill
for medical services, the health maintenance organization shall:
(1) Acknowledge receipt of the grievance in writing within 10 working days unless
it is resolved within that period of time;
(2) conduct a complete investigation of the grievance within 20 working days after
receipt of a grievance, unless the investigation cannot be completed within this period
of time. If the investigation cannot be completed within 20 working days after receipt of a
grievance, the enrollee shall be notified in writing within 30 working days time,
and every 30 working days after that, until the investigation is completed. The notice shall state the reasons for which additional time is needed for the investigation;
(3) have within five working days after the investigation is completed, someone not
involved in the circumstances giving rise to the grievance or its investigation decide
upon the appropriate resolution of the grievance and notify the enrollee in writing
of the decision of the health maintenance organization regarding the grievance and
of any right to appeal. The notice shall explain the resolution of the grievance and any right to appeal.
The notice shall explain the resolution of the grievance in terms which are clear
and specific; and
(4) notify, if the health maintenance organization has established a grievance advisory
panel, the enrollee of the enrollee's right to request the grievance advisory panel
to review the decision of the health maintenance organization. This notice shall indicate that the grievance advisory panel is not obligated to conduct
the review. This provision shall also state how, where and when the enrollee should make such
enrollee's request for this review.
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