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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 22. HEALTH |
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SubTilte 22-B. PUBLIC HEALTH AND MEDICINE |
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Chapter 22-B55. STANDARDS FOR PREPAID PROVIDERS QUALIFYING TO SERVE DISTRICT OF COLUMBIA MEDICAID RECIPIENTS |
Section 22-B5508. ENROLLEE GRIEVANCE SYSTEM
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5508.1 Each QO shall establish and maintain a grievance system with reasonable procedures for the prompt resolution of complaints initiated by enrollees.
5508.2 Each QO shall submit its plans and procedures for a grievance system to the Department for written approval prior to instituting the procedures.
5508.3 At a minimum, the following elements shall be included in the grievance system:
(a)A Grievance Committee for reviewing member complaints comprised of at least fifty percent (50%) QO members of which Medicaid enrollee representatives shall equal the percent of Medicaid enrollees to total enrollment; and
(b)Two (2) levels of review:
(1)Grievance Committee; and
(2)Board of Directors or its Grievance Subcommittee.
5508.4 Records of Grievance Committee and related hearings shall be maintained and available to the Department upon written request.
5508.5 Each QO shall submit to the Department an annual report of grievances, due within ninety (90) days of the close of its fiscal year, which shall include the following:
(a)The total number of grievances initiated by enrollees;
(b)A summary description of the types of grievance initiated; and
(c)A summary description of the actions taken to resolve grievances.