Ala. Admin. Code r. 420-5-6-.08

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-6-.08 - Complaint System

(1) A health maintenance organization shall have an enrollee complaint process, to include an informal review, a formal review, and an expedited formal review for the prompt resolution of complaints regarding such things as (a) the availability, delivery, or quality of health care service, (b) claims payment, handling or reimbursement for health care services, (c) matters pertaining to the administrative or contractual relationship, or both, between an enrollee and the health maintenance organization. Issues which can be resolved by telephone to the enrollee's satisfaction shall not be classified as a complaint.

(a) Inquiry means normal business operations conducted verbally or in writing between the health maintenance organization and enrollees. These inquiries may include such things as requests for identification cards, clarification of benefits, and address changes. Inquiries will be resolved to the enrollee's satisfaction and within a time frame that is acceptable to the enrollee. Inquiries shall be tracked and trended by issue involved to allow the health maintenance organization to identify systemic or commonly occurring areas.

(b) Informal Complaint means those issues that are not resolved to the members satisfaction at the inquiry level or for which the enrollee requests a written response. Informal complaints will be tracked in accordance with Chapter 420-5-6-.08(4).

(c) Formal complaint means the subsequent written expression by or on behalf of an enrollee regarding the resolution of an informal complaint. Discussions between a provider and the health maintenance organization during the utilization review process do not constitute a formal complaint. Authorization from the enrollee shall not be required for the provider's involvement in the utilization review process.

A provider may act on behalf of the enrollee in the formal complaint process if the physician certifies in writing that the enrollee is unable to act on his or her own behalf due to illness or disability. A family member, friend of the enrollee, or any other person may act on behalf of the enrollee after written notification to the health maintenance organization by the enrollee. A provider may also access the provider dispute mechanism as set forth in the provider contract without written authorization of the enrollee.

(d) Expedited Formal Complaint means a verbal or written request by the enrollee or the provider regarding an adverse medical necessity decision in the utilization review process. The request must describe the medical urgency of the situation to justify the expedited process.

(2) A health maintenance organization shall have a designated Alabama phone number and address for the receipt of enrollee complaints. A staff member shall be designated to oversee the complaint process.

(3) The complaint process, including the informal, formal, and expedited processes, must be fully described in enrollee contracts and enrollee handbooks.

(4) All informal, formal, and expedited complaints must be entered into a written or backed-up automated log.

(a) The log should include the nature of the complaint, date received, date action taken by the plan and date enrollee notified.

(5) The health maintenance organization shall have an informal complaint process.

(a) A decision regarding an informal complaint and the mailing of notice to the enrollee must take place within 45 calendar days of receipt of the informal complaint. The notification must detail the outcome of the informal complaint and in the case of an adverse outcome, advising of the right to file a formal complaint.

(b) A formal complaint shall be filed within twelve months of the health maintenance organization's receipt of the informal complaint. However, extenuating circumstances will be considered by the health maintenance organization.

(6) The health maintenance organization shall have a formal complaint process.

(a) The health maintenance organization shall maintain a record which demonstrates the health maintenance organization has considered all aspects of the enrollee's complaint.

(b) The enrollee and any other party of interest may provide pertinent data. The enrollee will be notified in writing of this right.

(c) At the request of the enrollee, the health maintenance organization shall appoint a member of its staff who has no direct involvement in the case to assist the enrollee. The enrollee shall be notified in writing of this right.

(d) The enrollee shall have the right to appear before the formal complaint committee.

(e) The medical director for the health maintenance organization shall determine the need to consult qualified specialty consultants during the formal review process.

(f) A review of the formal complaint shall be conducted by a committee of one or more individuals, who may be employees of the health maintenance organization. Committee members representing the health maintenance organization shall be employed by the health maintenance organization and be familiar with the policies and procedures of the Alabama health maintenance organization.

(g) The formal complaint committee shall render a decision within 30 calendar days of receipt of the written formal complaint. The enrollee must receive written notification regarding the resolution of the formal complaint within 5 working days of the decision detailing the outcome of the formal complaint. The notification shall provide notice that the enrollee may appeal to the state complaint committee through the

State Health Officer or the Commissioner of the Alabama Department of Insurance.

(h) The formal complaint committee will consider enrollee or provider requests for an expedited formal complaint review of an adverse medical necessity decision in the utilization review process. The request must support the fact that a standard response time could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. If justified for an expedited review, the committee shall render a decision within a time period that accommodates the clinical urgency of the situation. However, a decision must be made no later than three working days of receipt of the request. The provider's office will be notified either electronically or in writing on the day of the decision or on the next business day if the provider's office is closed, followed by written notification to the provider and enrollee within three working days of the decision. The notification shall provide notice that the enrollee may appeal to the state complaint committee through the State Health Officer or the Commissioner of the Alabama Department of Insurance.

(7) If the health maintenance organization delegates the receipt, investigation, decision-making, or communication piece of the complaint process to a contracted provider, the provider contract and health maintenance organization policy and procedure must adequately describe the delegated functions, required reporting to the health maintenance organization, and the health maintenance organization's ultimate responsibility for the process.

(8) The health maintenance organization shall maintain records of all complaints and shall include in quarterly and annual reports to the Department the total number of complaints received and the number of complaints unresolved.

(9) If a complaint concerns any provider with whom a health maintenance organization contracts, the Department may make an examination concerning health care services of the health maintenance organization and provider.

Author: Department of Public Health

Ala. Admin. Code r. 420-5-6-.08

Filed September 1, 1982. Repealed and New Rule adopted in lieu thereof: Filed March 31, 1987. Amended: Filed January 20, 1999; effective February 24, 1999.

Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.