(1)If a covered person makes a request to a health carrier for a health care
service and the request is denied, the health carrier shall provide the covered
person with an explanation of the reasons for the denial, a written notice
of how to submit a grievance, and the telephone number to call for information
and assistance. The health carrier, at the time of a determination not to
certify an admission, a continued stay, or other health care service, shall
inform the attending or ordering provider of the right to submit a grievance
or a request for an expedited review and, upon request, shall explain the
procedures established by the health carrier for initiating a review. A grievance
involving an adverse determination may be submitted by the covered person,
the covered person's represent
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(1)
If a covered person makes a request to a health carrier for a health care
service and the request is denied, the health carrier shall provide the covered
person with an explanation of the reasons for the denial, a written notice
of how to submit a grievance, and the telephone number to call for information
and assistance. The health carrier, at the time of a determination not to
certify an admission, a continued stay, or other health care service, shall
inform the attending or ordering provider of the right to submit a grievance
or a request for an expedited review and, upon request, shall explain the
procedures established by the health carrier for initiating a review. A grievance
involving an adverse determination may be submitted by the covered person,
the covered person's representative, or a provider acting on behalf of a covered
person, except that a provider may not submit a grievance involving an adverse
determination on behalf of a covered person in a situation in which federal
or other state law prohibits a provider from taking that action. A health
carrier shall ensure that a majority of the persons reviewing a grievance
involving an adverse determination have appropriate expertise. A health carrier
shall issue a copy of the written decision to a provider who submits a grievance
on behalf of a covered person. A health carrier shall conduct a review of a grievance
involving an adverse determination in accordance with subsection (3) of this
section and section 44-7310 , but such a grievance is not subject to the grievance
register reporting requirements of section 44-7306 unless it is a written
grievance.
(2)(a) A grievance concerning any matter except an adverse
determination may be submitted by a covered person or a covered person's representative.
A health carrier shall issue a written decision to the covered person or the
covered person's representative within fifteen working days after receiving
a grievance. The person or persons reviewing the grievance shall not be the
same person or persons who made the initial determination denying a claim
or handling the matter that is the subject of the grievance. If the health
carrier cannot make a decision within fifteen working days due to circumstances
beyond the health carrier's control, the health carrier may take up to an
additional fifteen working days to issue a written decision, if the health
carrier provides written notice to the covered person of the extension and
the reasons for the delay on or before the fifteenth working day after receiving
a grievance.
(b) A covered person does not have the right to attend, or
to have a representative in attendance, at the grievance review. A covered person
is entitled to submit written material. The health carrier shall provide the
covered person the name, address, and telephone number of a person designated
to coordinate the grievance review on behalf of the health carrier. The health
carrier shall make these rights known to the covered person within three working
days after receiving a grievance.
(3) The written decision issued pursuant to the procedures
described in subsections (1) and (2) of this section and section 44-7310 shall
contain:
(a) The names, titles, and qualifying credentials of the person
or persons acting as the reviewer or reviewers participating in the grievance review
process;
(b) A statement of the reviewers' understanding of the covered
person's grievance;
(c) The reviewers' decision in clear terms and the contract
basis or medical rationale in sufficient detail for the covered person to
respond further to the health carrier's position;
(d) A reference to the evidence or documentation used as the
basis for the decision;
(e) In cases involving an adverse determination, the instructions
for requesting a written statement of the clinical rationale, including the
clinical review criteria used to make the determination; and
(f) Notice
of the covered person's right to contact the director's office. The notice
shall contain the telephone number and address of the director's office.