1. Each managed care organization shall establish a system for resolving complaints
of an insured concerning:
(a) Payment or reimbursement for covered health care services;
(b) Availability, delivery or quality of covered health care services, including,
without limitation, an adverse determination made pursuant to utilization review;
(c) The terms and conditions of a health care plan.
The system must be approved by the Commissioner.
2. If an insured makes an oral complaint, a managed care organization shall inform
the insured that if the insured is not satisfied with the resolution of the complaint,
the insured must file the complaint in writing to receive further review of the complaint.
3. Each managed care organization shall:
(a) Upon request, assign an employee of the managed care organization to assist an
insured or other person in filing a complaint or appealing a decision of the review
(b) Authorize an insured who appeals a decision of the review board to appear before
the review board to present testimony at a hearing concerning the appeal; and
(c) Authorize an insured to introduce any documentation into evidence at a hearing
of a review board and require an insured to provide the documentation required by
the health care plan of the insured to the review board not later than 5 business
days before a hearing of the review board.
4. The Commissioner may examine the system for resolving complaints established pursuant
to this section at such times as the Commissioner deems necessary or appropriate.
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