Section 22-B6002. INFORMAL INTERNAL REVIEW

 

6002.1Any member dissatisfied with an adverse decision shall be provided an opportunity to discuss and review the decision with the insurer's medical director, physician or other designee who rendered the decision.

 

6002.2The member has the right to designate a member representative to participate in the grievance process.

 

6002.3Each informal internal review shall be concluded as soon as possible, considering the medical exigencies of the review, but not later than fourteen (14) business days after the request for an informal internal review has been filed, except as provided in § 6002.4.

 

6002.4If a request for an informal internal review results from a decision involving an urgent or emergency medical condition, the review shall be concluded within twenty-four (24) hours of receipt of the notification from the member or member representative.

 

6002.5Each insurer shall provide a written explanation of a grievance decision to the member or member representative and shall notify the member or member representative of the right to request a formal internal review of the decision.

 

6002.6Each written explanation provided pursuant to § 6002.5 shall set forth the information required by § 6001.4.

 

source

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