(a)Every health maintenance organization shall establish and maintain a complaint system providing reasonable procedures for resolving complaints initiated by enrollees. Nothing herein shall be construed to preclude an enrollee or a provider from filing a complaint with the Director or as limiting the Director's ability to investigate such complaints.
(b)When a complaint is received by the Department of Insurance against a health maintenance organization or producer (respondent), the respondent, shall be notified of the complaint. The Department shall, in its notification, specify the date when a report is to be received from the respondent, which shall be no later than 21 days after notification is sent to the respondent. A failure to reply by the date specified may be followed by a col
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(a) Every health maintenance organization shall establish and maintain a complaint system providing reasonable procedures for resolving complaints initiated by enrollees. Nothing herein shall be construed to preclude an enrollee or a provider from filing a complaint with the Director or as limiting the Director's ability to investigate such complaints. (b) When a complaint is received by the Department of Insurance against a health maintenance organization or producer (respondent), the respondent, shall be notified of the complaint. The Department shall, in its notification, specify the date when a report is to be received from the respondent, which shall be no later than 21 days after notification is sent to the respondent. A failure to reply by the date specified may be followed by a collect telephone call or collect telegram. Repeated instances of failing to reply by the date specified may result in further regulatory action. (c) Contents of Response or Report. (1) Each respondent shall supply adequate documentation which explains all actions taken or not taken and which were the basis for the complaint; (2) Documents necessary to support the respondent's position and information requested by the Department, shall be furnished with the respondent's reply; (3) The respondent's reply shall be in duplicate, but duplicate copies of supporting documents shall not be required; (4) The respondent's reply shall include the name, telephone number and address of the individual assigned to the complaint; and (5) The Department shall respect the confidentiality of medical reports and other documents which by law are confidential. Any other information furnished by a respondent shall be marked "confidential" if the respondent does not wish it to be released to the complainant. (d) Follow-up Conclusion. Upon receipt of the respondent's report, the investigating deputy shall evaluate the material submitted; and (1) Advise the complainant of the action taken and disposition of his complaint; (2) Pursue further investigation with respondent or complainant; or (3) Refer the investigation report to the appropriate branch within the Department of Insurance for further regulatory action.