§ 58-50-62. Insurer grievance procedures.
§ 58‑50‑62. Insurer grievance procedures.
(a) Purpose and Intent. The purpose of this section is to provide standards for the establishment andmaintenance of procedures by insurers to assure that covered persons have theopportunity for appropriate resolutions of their grievances.
(b) Availability ofGrievance Process. Every insurer shall have a grievance process whereby acovered person may voluntarily request a review of any decision, policy, oraction of the insurer that affects that covered person. A decision renderedsolely on the basis that the health benefit plan does not provide benefits forthe health care service in question is not subject to the insurer's grievanceprocedures, if the exclusion of the specific service requested is clearly statedin the certificate of coverage. The grievance process may provide for animmediate informal consideration by the insurer of a grievance. If the insurerdoes not have a procedure for informal consideration or if an informalconsideration does not resolve the grievance, the grievance process shallprovide for first‑ and second‑level reviews of grievances. Appealof a noncertification that has been reviewed under G.S. 58‑50‑61shall be reviewed as a second‑level grievance under this section.
(b1) Informal Considerationof Grievances. If the insurer provides procedures for informal considerationof grievances, the procedures shall be in writing, and the followingrequirements apply:
(1) If the grievanceconcerns a clinical issue and the informal consideration decision is not infavor of the covered person, the insurer shall treat the request as a requestfor a first‑level grievance review, except that the requirements ofsubdivision (e) (1) of this section apply on the day the decision is made or onthe tenth business day after receipt of the request for informal consideration,whichever is sooner;
(2) If the grievanceconcerns a nonclinical issue and the informal consideration decision is not infavor of the covered person, the insurer shall issue a written decision thatincludes the information set forth in subsection (c) of this section; or
(3) If the insurer isunable to render an informal consideration decision within 10 business daysafter receipt of the grievance, the insurer shall treat the request as arequest for a first‑level grievance review, except that the requirementsof subdivision (e) (1) of this section apply beginning on the day the insurerdetermines an informal consideration decision cannot be made before the tenthbusiness day after receipt of the grievance.
(c) GrievanceProcedures. Every insurer shall have written procedures for receiving andresolving grievances from covered persons. A description of the grievanceprocedures shall be set forth in or attached to the certificate of coverage andmember handbook provided to covered persons. The description shall include astatement informing the covered person that the grievance procedures arevoluntary and shall also inform the covered person about the availability ofthe Commissioner's office for assistance, including the telephone number andaddress of the office. The description shall also inform the covered personabout the availability of assistance from the Managed Care Patient AssistanceProgram, including the telephone number and address of the Program.
(d) Maintenance ofRecords. Every insurer shall maintain records of each grievance received andthe insurer's review of each grievance, as well as documentation sufficient todemonstrate compliance with this section. The maintenance of these records,including electronic reproduction and storage, shall be governed by rulesadopted by the Commissioner that apply to insurers. The insurer shall retainthese records for five years or, for domestic companies, until the Commissionerhas adopted a final report of a general examination that contains a review ofthese records for that calendar year, whichever is later.
(e) First‑LevelGrievance Review. A covered person or a covered person's provider acting onthe covered person's behalf may submit a grievance.
(1) The insurer does nothave to allow a covered person to attend the first‑level grievancereview. A covered person may submit written material. Except as provided insubdivision (3) of this subsection, within three business days after receivinga grievance, the insurer shall provide the covered person with the name,address, and telephone number of the coordinator and information on how tosubmit written material.
(2) An insurer shallissue a written decision, in clear terms, to the covered person and, ifapplicable, to the covered person's provider, within 30 days after receiving agrievance. The person or persons reviewing the grievance shall not be the sameperson or persons who initially handled the matter that is the subject of thegrievance and, if the issue is a clinical one, at least one of whom shall be amedical doctor with appropriate expertise to evaluate the matter. Except asprovided in subdivision (3) of this subsection, if the decision is not in favorof the covered person, the written decision issued in a first‑levelgrievance review shall contain:
a. The professionalqualifications and licensure of the person or persons reviewing the grievance.
b. A statement of thereviewers' understanding of the grievance.
c. The reviewers'decision in clear terms and the contractual basis or medical rationale insufficient detail for the covered person to respond further to the insurer'sposition.
d. A reference to theevidence or documentation used as the basis for the decision.
e. A statement advisingthe covered person of his or her right to request a second‑levelgrievance review and a description of the procedure for submitting a second‑levelgrievance under this section.
f. Notice of theavailability of assistance from the Managed Care Patient Assistance Program,including the telephone number and address of the Program.
(3) For grievancesconcerning the quality of clinical care delivered by the covered person'sprovider, the insurer shall acknowledge the grievance within 10 business days.The acknowledgement shall advise the covered person that (i) the insurer willrefer the grievance to its quality assurance committee for review andconsideration or any appropriate action against the provider and (ii) State lawdoes not allow for a second‑level grievance review for grievancesconcerning quality of care.
(f) Second‑LevelGrievance Review. An insurer shall establish a second‑level grievancereview process for covered persons who are dissatisfied with the first‑levelgrievance review decision or a utilization review appeal decision. A coveredperson or the covered person's provider acting on the covered person's behalfmay submit a second‑level grievance.
(1) An insurer shall,within 10 business days after receiving a request for a second‑levelgrievance review, make known to the covered person:
a. The name, address,and telephone number of a person designated to coordinate the grievance reviewfor the insurer.
b. A statement of acovered person's rights, which include the right to request and receive from aninsurer all information relevant to the case; attend the second‑levelgrievance review; present his or her case to the review panel; submitsupporting materials before and at the review meeting; ask questions of anymember of the review panel; and be assisted or represented by a person of hisor her choice, which person may be without limitation to: a provider, familymember, employer representative, or attorney. If the covered person chooses tobe represented by an attorney, the insurer may also be represented by anattorney.
c. The availability ofassistance from the Managed Care Patient Assistance Program, including thetelephone number and address of the Program.
(2) An insurer shallconvene a second‑level grievance review panel for each request. The panelshall comprise persons who were not previously involved in any matter givingrise to the second‑level grievance, are not employees of the insurer orURO, and do not have a financial interest in the outcome of the review. A personwho was previously involved in the matter may appear before the panel topresent information or answer questions. All of the persons reviewing a second‑levelgrievance involving a noncertification or a clinical issue shall be providerswho have appropriate expertise, including at least one clinical peer. Provided,however, an insurer that uses a clinical peer on an appeal of anoncertification under G.S. 58‑50‑61 or on a first‑levelgrievance review panel under this section may use one of the insurer's employeeson the second‑level grievance review panel in the same matter if thesecond‑level grievance review panel comprises three or more persons.
(g) Second‑LevelGrievance Review Procedures. An insurer's procedures for conducting a second‑levelgrievance review shall include:
(1) The review panelshall schedule and hold a review meeting within 45 days after receiving arequest for a second‑level review.
(2) The covered personshall be notified in writing at least 15 days before the review meeting date.
(3) The covered person'sright to a full review shall not be conditioned on the covered person'sappearance at the review meeting.
(h) Second‑LevelGrievance Review Decisions. An insurer shall issue a written decision to thecovered person and, if applicable, to the covered person's provider, withinseven business days after completing the review meeting. The decision shallinclude:
(1) The professionalqualifications and licensure of the members of the review panel.
(2) A statement of thereview panel's understanding of the nature of the grievance and all pertinentfacts.
(3) The review panel'srecommendation to the insurer and the rationale behind that recommendation.
(4) A description of orreference to the evidence or documentation considered by the review panel inmaking the recommendation.
(5) In the review of anoncertification or other clinical matter, a written statement of the clinicalrationale, including the clinical review criteria, that was used by the reviewpanel to make the recommendation.
(6) The rationale forthe insurer's decision if it differs from the review panel's recommendation.
(7) A statement that thedecision is the insurer's final determination in the matter. In cases where thereview concerned a noncertification and the insurer's decision on the second‑levelgrievance review is to uphold its initial noncertification, a statementadvising the covered person of his or her right to request an external reviewand a description of the procedure for submitting a request for external reviewto the Commissioner of Insurance.
(8) Notice of theavailability of the Commissioner's office for assistance, including thetelephone number and address of the Commissioner's office.
(9) Notice of theavailability of assistance from the Managed Care Patient Assistance Program,including the telephone number and address of the Program.
(i) Expedited Second‑LevelProcedures. An expedited second‑level review shall be made availablewhere medically justified as provided in G.S. 58‑50‑61(l), whetheror not the initial review was expedited. The provisions of subsections (f),(g), and (h) of this section apply to this subsection except for the followingtimetable: When a covered person is eligible for an expedited second‑levelreview, the insurer shall conduct the review proceeding and communicate itsdecision within four days after receiving all necessary information. The reviewmeeting may take place by way of a telephone conference call or through theexchange of written information.
(j) No insurer shall discriminateagainst any provider based on any action taken by the provider under thissection or G.S. 58‑50‑61 on behalf of a covered person.
(k) Violation. Aviolation of this section subjects an insurer to G.S. 58‑2‑70. (1997‑519, s. 4.2;2001‑417, ss. 8‑11; 2001‑446, s. 4.6; 2003‑105, s. 2(a)‑(d);2008‑124, s. 5.2.)