First- and second-level grievance review for managed care plans, first-level procedures
1. A health carrier that offers managed care plans shall establish a first-level and second-level grievance review process for its managed care plans. A grievance may be submitted by an enrollee, an enrollee’s representative or a provider acting on behalf of an enrollee.
2. Upon receipt of a request for first-level grievance review, a health carrier shall:
(1) Acknowledge receipt in writing of the grievance within ten working days;
(2) Conduct a complete investigation of the grievance within twenty working days after receipt of a grievance, unless the investigation cannot be completed within this time. If the investigation cannot be completed within twenty working days after receipt of a grievance, the enrollee shall be notified in writing on or before the twentieth working day and the investigation shall be completed within thirty working days thereafter. The notice shall set forth with specificity the reasons for which additional time is needed for the investigation;
(3) Within five working days after the investigation is completed, have someone not involved in the circumstances giving rise to the grievance or its investigation decide upon the appropriate resolution of the grievance and notify the enrollee in writing of the health carrier’s decision regarding the grievance and of the right to file an appeal for a second-level review. The notice shall explain the resolution of the grievance and the right to appeal in terms which are clear and specific;
(4) Within fifteen working days after the investigation is completed, notify the person who submitted the grievance of the carrier’s resolution of said grievance.