Section 22-B6000. ESTABLISHMENT OF INTERNAL GRIEVANCE PROCESS

 

6000.1Each insurer shall establish and maintain an internal grievance system that provides for the presentation and resolution of grievances brought by members or member representatives.

 

6000.2A member or member representative shall have a right to file a grievance with an insurer for a review of an adverse decision.

 

6000.3Each insurer shall provide each member with written notice in English or Spanish, as appropriate, of the components of a grievance as required by § 6001.1 (a) and (b) at the time the member first enrolls with the insurer. The notice shall also include:

 

(a)The telephone numbers and business addresses of the insurer's representatives responsible for grievance resolution;

 

(b)A statement that describes a member's or member representative's right to contact the Director if dissatisfied with the resolution reached through the insurer's internal grievance system; and

 

(c)A statement that describes a Medicaid enrollee's right to appeal externally to the Office of Fair Hearings at any time, if applicable.

 

6000.4Each insurer shall:

 

(a)File with the Director a copy of its internal grievance procedures within sixty (60) business days after the effective date of these rules;

 

(b)File with the Director any amendment to its internal grievance procedures at least thirty (30) business days before the effective date of the amendment;

 

(c)Include with the filing required under §6000.4 (a) a copy of the notice, plan, certificate, enrollment materials, contract or other evidence of their coverage, as well as sample notices of grievance denials and any other notices to be used by the insurer in administering the grievance system; and

 

(d)Submit to the Director an annual grievance report not later than October 30th of each year that includes:

 

(1)The name and location of the reporting insurer;

 

(2)The applicable reporting period;

 

(3)The names of the individuals responsible for the operation of the insurer's grievance process;

 

(4)The total number of grievances received by the insurer, categorized by cause, insurance status, and disposition;

 

(5)The total number of requests for expedited review categorized by cause, length of time for resolution, and disposition;

 

(6)The total number of requests for external review, categorized by cause, length of time for resolution and disposition; and

 

(7)A description of any changes that have been made to the grievance process during the preceding year.

 

6000.5The Director may request additional information from the insurer, and the insurer shall respond to such requests for additional information within ten (10) business days.

 

6000.6An insurer shall not limit, reduce, terminate or otherwise change the services to be provided by the insurer, or take any other action to diminish the rights of the member or services to be rendered to the member, solely because the member exercised grievance or review rights pursuant to the Act or this chapter.

 

authority

Unless otherwise noted, the authority for this chapter is the Health Benefits Plan Members Bill of Rights Act of 1998 § 401, D.C. Code, 2001 Ed. § 44-304.01; and Mayor’s Order 99-159 (October 13, 1999).

source

Final Rulemaking published at 47 DCR 229 (January 14, 2000).