P.R. Laws tit. 26, § 9395
(a) Health insurance organizations or issuers shall maintain written records to document all grievances received during a calendar year (the register).
(b) A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with § 9397 of this title. A request for a standard review of a grievance not involving an adverse determination shall be processed in compliance with § 9398 of this title.
(c) A request for an additional voluntary review of a grievance shall be processed in compliance with § 9399 of this title.
(d) For each grievance, the register shall contain at least the following information:
(1) A general description of the reason(s) for the grievance;
(2) the date received;
(3) the date of each review or, if applicable, review meeting;
(4) decision/resolution at each level of the grievance, if applicable;
(5) date of decision/resolution at each level, if applicable, and
(6) name of the covered person or enrollee for whom the grievance was filed.
(e) The register shall be maintained in a manner that is clear and accessible to the Commissioner.
(f)
(1) Health insurance organizations or issuers shall retain the register compiled for a calendar year for the longer of five (5) years or until the Commissioner has issued a final report of an examination that contains a review of the register for that calendar year.
(2)
(A) Health insurance organizations or issuers shall submit to the Commissioner, at least annually, a report in the format specified by him/her.
(B) The report shall include the following for each type of health plan offered by the health insurance organization or issuer:
(i) The certificate of compliance required by § 9396(c) of this title;
(ii) the number of covered persons or enrollees;
(iii) the total number of grievances;
(iv) the number of grievances for which a covered person or enrollee requested an additional voluntary grievance review pursuant to § 9399 of this title;
(v) the number of grievances resolved at each level, if applicable, and their decision/resolution;
(vi) the number of grievances appealed to the Commissioner of which the health insurance organization or issuer has been informed;
(vii) the number of grievances referred to alternative dispute resolution procedures, such as mediation or arbitration, or resulting in litigation, and
(viii) a synopsis of actions taken to correct the problems identified.
History —Aug. 29, 2011, No. 194, § 22.050, eff. 180 days after Aug. 29, 2011.