§432E-5 - Complaints and appeals procedure for enrollees.
§432E-5 Complaints and appeals procedure for enrollees. (a) A managed care plan with enrollees in this State shall establish and maintain a procedure to provide for the resolution of an enrollee's complaints and appeals. The procedure shall provide for expedited appeals under section 432E-6.5. The definition of medical necessity in section 432E-1.4 shall apply in a managed care plan's complaints and appeals procedures.
(b) The managed care plan shall at all times make available its complaints and appeals procedures. The complaints and appeals procedures shall be reasonably understandable to the average layperson and shall be provided in a language other than English upon request.
(c) A managed care plan shall decide any expedited appeal as soon as possible after receipt of the complaint, taking into account the medical exigencies of the case, but not later than seventy-two hours after receipt of the request for expedited appeal.
(d) A managed care plan shall send notice of its final internal determination within sixty days of the submission of the complaint to the enrollee, the enrollee's appointed representative, if applicable, the enrollee's treating provider, and the commissioner. The notice shall include the following information regarding the enrollee's rights and procedures:
(1) The enrollee's right to request an external review;
(2) The sixty-day deadline for requesting the external review;
(3) Instructions on how to request an external review; and
(4) Where to submit the request for an external review. [L 1998, c 178, pt of §2; am L 1999, c 137, §5; am L 2000, c 250, §4; am L 2004, c 27, §1]