§ 4408-A*2 — Grievance procedure

* § 4408-a. Grievance procedure. 1. A health maintenance organization\nlicensed pursuant to article forty-three of the insurance law or\ncertified pursuant to this article, and any other organization certified\npursuant to this article shall establish and maintain a grievance\nprocedure. Pursuant to such procedure, enrollees shall be entitled to\nseek a review of determinations by the organization other than\ndeterminations subject to the provisions of article forty-nine of this\nchapter.\n 2. (a) An organization shall provide to all enrollees written notice\nof the grievance procedure in the member handbook and at any time that\nthe organization denies access to a referral or determines that a\nrequested benefit is not covered pursuant to the terms of the contract;\nprovided, however, that nothing herein shall be deemed to require a\nhealth care provider to provide such notice. In the event that an\norganization denies a service as an adverse determination as defined in\narticle forty-nine of this chapter, the organization shall inform the\nenrollee or the enrollee's designee of the appeal rights provided for in\narticle forty-nine of this chapter.\n (b) The notice to an enrollee describing the grievance process shall\nexplain: (i) the process for filing a grievance with the organization;\n(ii) the timeframes within which a grievance determination must be made;\n(iii) the right of an enrollee to designate a representative to file a\ngrievance on behalf of the enrollee; and (iv) notice of the name,\naddress, phone number and website of the department designated consumer\nassistance program and the independent substance use disorder and mental\nhealth ombudsman established by section 33.27 of the mental hygiene law\nwithin notices of adverse grievances and appeals determinations.\n (c) The organization shall assure that the grievance procedure is\nreasonably accessible to those who do not speak English.\n 3. (a) The organization may require an enrollee to file a grievance in\nwriting, by letter or by a grievance form which shall be made available\nby the organization and which shall conform to applicable standards for\nreadability.\n (b) Notwithstanding the provisions of paragraph (a) of this\nsubdivision, an enrollee may submit an oral grievance in connection\nwith: (i) a denial of, or failure to pay for, a referral; or (ii) a\ndetermination as to whether a benefit is covered pursuant to the terms\nof the enrollee's contract. In connection with the submission of an oral\ngrievance, an organization may require that the enrollee sign a written\nacknowledgment of the grievance prepared by the organization summarizing\nthe nature of the grievance. Such acknowledgment shall be mailed\npromptly to the enrollee, who shall sign and return the acknowledgment,\nwith any amendments, in order to initiate the grievance. The grievance\nacknowledgment shall prominently state that the enrollee must sign and\nreturn the acknowledgment to initiate the grievance. If an organization\ndoes not require such a signed acknowledgment, an oral grievance shall\nbe initiated at the time of the telephone call.\n (c) Upon receipt of a grievance, the organization shall provide notice\nspecifying what information must be provided to the organization in\norder to render a decision on the grievance.\n (d) (1) An organization shall designate personnel to accept the filing\nof an enrollee's grievance by toll-free telephone no less than forty\nhours per week during normal business hours and, shall have a telephone\nsystem available to take calls during other than normal business hours\nand shall respond to all such calls no less than the next business day\nafter the call was recorded.\n (2) Notwithstanding the provisions of subparagraph one of this\nparagraph, an organization may, in the alternative, designate personnel\nto accept the filing of an enrollee's grievance by toll-free telephone\nnot less than forty hours per week during normal business hours and, in\nthe case of grievances subject to subparagraph (i) of subdivision four\nof this section, on a twenty-four hour a day, seven day a week basis.\n 4. Within fifteen business days of receipt of the grievance, the\norganization shall provide written acknowledgment of the grievance,\nincluding the name, address and telephone number of the individual or\ndepartment designated by the organization to respond to the grievance.\nAll grievances shall be resolved in an expeditious manner, and in any\nevent, no more than: (i) forty-eight hours after the receipt of all\nnecessary information when a delay would significantly increase the risk\nto an enrollee's health; (ii) thirty days after the receipt of all\nnecessary information in the case of requests for referrals or\ndeterminations concerning whether a requested benefit is covered\npursuant to the contract; and (iii) forty-five days after the receipt of\nall necessary information in all other instances.\n 5. The organization shall designate one or more qualified personnel to\nreview the grievance; provided further, that when the grievance pertains\nto clinical matters, the personnel shall include, but not be limited to,\none or more licensed, certified or registered health care professionals.\n 6. The notice of a determination of the grievance shall be made in\nwriting to the enrollee or to the enrollee's designee. In the case of a\ndetermination made in conformance with subparagraph (i) of subdivision\nfour of this section, notice shall be made by telephone directly to the\nenrollee with written notice to follow within three business days.\n 7. The notice of a determination shall include: (i) the detailed\nreasons for the determination; (ii) in cases where the determination has\na clinical basis, the clinical rationale for the determination; (iii)\nthe procedures for the filing of an appeal of the determination,\nincluding a form for the filing of such an appeal; and (iv) notice of\nthe name, address, phone number and website of the department designated\nconsumer assistance program and the independent substance use disorder\nand mental health ombudsman established by section 33.27 of the mental\nhygiene law within notices of adverse grievances and appeals\ndeterminations.\n 8. An enrollee or an enrollee's designee shall have not less than\nsixty business days after receipt of notice of the grievance\ndetermination to file a written appeal, which may be submitted by letter\nor by a form supplied by the organization.\n 9. Within fifteen business days of receipt of the appeal, the\norganization shall provide written acknowledgment of the appeal,\nincluding the name, address and telephone number of the individual\ndesignated by the organization to respond to the appeal and what\nadditional information, if any, must be provided in order for the\norganization to render a decision.\n 10. The determination of an appeal on a clinical matter must be made\nby personnel qualified to review the appeal, including licensed,\ncertified or registered health care professionals who did not make the\ninitial determination, at least one of whom must be a clinical peer\nreviewer as defined in article forty-nine of this chapter. The\ndetermination of an appeal on a matter which is not clinical shall be\nmade by qualified personnel at a higher level than the personnel who\nmade the grievance determination.\n 11. The organization shall seek to resolve all appeals in the most\nexpeditious manner and shall make a determination and provide notice no\nmore than:\n (i) two business days after the receipt of all necessary information\nwhen a delay would significantly increase the risk to an enrollee's\nhealth; and\n (ii) thirty business days after the receipt of all necessary\ninformation in all other instances.\n 12. The notice of a determination on an appeal shall include: (i) the\ndetailed reasons for the determination; and (ii) in cases where the\ndetermination has a clinical basis, the clinical rationale for the\ndetermination.\n 13. An organization shall not retaliate or take any discriminatory\naction against an enrollee because an enrollee has filed a grievance or\nappeal.\n 14. An organization shall maintain a file on each grievance and\nassociated appeal, if any, that shall include the date the grievance was\nfiled; a copy of the grievance, if any; the date of receipt of and a\ncopy of the enrollee's acknowledgment of the grievance, if any; the\ndetermination made by the organization including the date of the\ndetermination and the titles and, in the case of a clinical\ndetermination, the credentials of the organization's personnel who\nreviewed the grievance. If an enrollee files an appeal of the grievance,\nthe file shall include the date and a copy of the enrollee's appeal, the\ndetermination made by the organization including the date of the\ndetermination and the titles and, in the case of clinical\ndeterminations, the credentials, of the organization's personnel who\nreviewed the appeal.\n 15. An organization shall have procedures for obtaining an enrollee's,\nor enrollee's designee's, preference for receiving notifications, which\nshall be in accordance with applicable federal law and with guidance\ndeveloped by the commissioner. Written and telephone notification to an\nenrollee or the enrollee's designee under this section may be provided\nby electronic means where the enrollee or the enrollee's designee has\ninformed the organization in advance of a preference to receive such\nnotification by electronic means. An organization shall permit the\nenrollee and the enrollee's designee to change the preference at any\ntime. The organization shall retain documentation of preferred\nnotification methods and present such records to the commissioner upon\nrequest.\n 16. The rights and remedies conferred in this article upon enrollees\nshall be cumulative and in addition to and not in lieu of any other\nrights or remedies available under law.\n * NB There are 2 § 4408-a's\n