Section 22-B6001. REQUIREMENTS FOR INTERNAL GRIEVANCE SYSTEM

 

6001.1Each insurer's internal grievance system shall include the following:

 

(a)The right of a member or member representative to file a grievance regarding any aspect of the insurer's health care services related to the adverse decision by the insurer;

 

(b)A procedure for filing a review from a grievance decision by the insurer;

 

(c)A procedure for recording, documenting, and reporting to the Director the status of all grievances;

 

(d)The availability of a member services representative to assist members with filing a grievance each business day during regular business hours;

 

(e)The right of a member to designate an outside independent representative or representatives to assist the member in following the grievance procedures;

 

(f)A specific time for responding to reviews of adverse grievance decisions;

 

(g)Oral and written procedures disseminated to members describing how grievances are processed and resolved;

 

(h) Procedures for notifying a member or member representative when additional information is required to process a grievance, and the method to be used to inform all parties of resolution;

 

(i)An expedited grievance procedure for use in cases involving urgent or emergency medical conditions whereby a member or member representative may request expedited informal or formal review;

 

(j)Procedures governing urgent or emergency medical conditions which specify:

 

(1)How a member may request an expedited review;

 

(2)The title of the employee and an alternate who will expedite reviews when a grievant asserts an emergency case;

 

(3)The factors to be considered in making the determination about the existence of an emergency case; and

 

(4)The method for communicating to the member or member representative any decision regarding an urgent or emergency medical condition;

 

(k)Procedures to allow a grievance to be filed on behalf of a member by a member representative; and

 

(l)Provisions that require the insurer to:

 

(1)Orally communicate any grievance decision to the member or member representative made by the insurer; and

 

(2)Within five (5) business days after the grievance decision has been made, send the written grievance decision to the member or the member representative.

 

6001.2All grievance records shall be maintained for three (3) years from the date of final resolution and shall be made available for inspection by the member, member representative or Director upon request. Each request to review records shall be granted within five (5) business days of the request.

 

6001.3If an insurer reduces or terminates services contrary to the recommendation of a treating physician or advance practice registered nurse, the insurer shall provide the member or member representative with twenty-four (24) hours prior verbal notification, and shall issue a written decision as soon as practicable, but not more than five (5) business days after the decision.

 

6001.4The written grievance decision shall include the following:

 

(a)The reviewer's understanding of the grievance;

 

(b)The reviewer's decision in clear terms;

 

(c)The contractual basis or medical reason in sufficient detail for the member or member representative to understand and respond to the insurer's position, provided that general terms such as "experimental procedures not covered", "cosmetic procedures not covered", "service included under another procedure", and "not medically necessary" shall not be used, unless reference is made to a specific provision or medical evidence that verifies the insurer's position; and

 

(d)All applicable instructions, including the telephone numbers and titles of persons to contact, and applicable time frames to request a review of the decision at the next level in at least 12 point type face.

 

source

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