Sec. 7. (a) A health maintenance organization shall establish written policies and procedures for the timely resolution of grievances filed under this chapter. The policies and procedures must include the following:
(1) An acknowledgment of the grievance, orally or in writing, to the enrollee or subscriber within three (3) business days.
(2) Documentation of the substance of the grievance and any actions taken.
(3) An investigation of the substance of the grievance, including any aspects involving clinical care.
(4) Notification to the enrollee or subscriber of the disposition of the grievance and the right to appeal.
(5) Standards for timeliness in responding to complaints and providing notice to enrollees and subscribers of the disposition of the complaint and the right to appeal that accommodate the clinical urgency of the situation.
(b) The health maintenance organization shall appoint at least one (1) individual to resolve the complaint.
(c) A grievance must be resolved as expeditiously as possible, but not more than twenty (20) business days after the grievance is filed. If a health maintenance organization is unable to make a decision regarding the grievance within the twenty (20) day period due to circumstances beyond the health maintenance organization's control, the health maintenance organization shall:
(1) notify the enrollee or subscriber in writing of the reason for the delay before the twentieth business day; and
(2) issue a written decision regarding the complaint within an additional ten (10) business days.
(d) A health maintenance organization shall notify the enrollee or subscriber in writing of the resolution of the grievance within five (5) business days after completing the investigation. The grievance resolution notice must contain the following:
(1) The decision reached by the health maintenance organization.
(2) The reasons, policies, and procedures that are the basis of the decision.
(3) Notice of the enrollee's or subscriber's right to appeal the decision.
(4) The department, address, and telephone number through which an enrollee may contact a qualified representative to obtain more information about the decision or the right to appeal.
As added by P.L.191-1997, SEC.9.
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