Approval; requirements; assistance for persons filing complaints; examination.
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; or
(c) The terms and conditions of a health care plan.
Ê The system must be approved by the Commissioner in consultation with the State Board of Health.
2. If an insured makes an oral complaint, a managed care organization shall inform the insured that if he is not satisfied with the resolution of the complaint, he 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 board;
(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 his health care plan to the review board not later than 5 business days before a hearing of the review board.
4. The Commissioner or the State Board of Health may examine the system for resolving complaints established pursuant to this section at such times as either deems necessary or appropriate.
Last modified: February 27, 2006