32.1-137.6 - Complaint system.
§ 32.1-137.6. Complaint system.
A. Each managed care health insurance plan licensee subject to § 32.1-137.2shall establish and maintain for each of its managed care health insuranceplans a complaint system approved by the Commissioner and the Bureau ofInsurance to provide reasonable procedures for the resolution of writtencomplaints in accordance with the requirements established under this articleand Title 38.2, and shall include the following:
1. A record of the complaints shall be maintained for the period set forth in§ 32.1-137.16 for review by the Commissioner.
2. Each managed care health insurance plan licensee shall provide complaintforms and/or written procedures to be given to covered persons who wish toregister written complaints. Such forms or procedures shall include theaddress and telephone number of the managed care licensee to which complaintsshall be directed and the mailing address, telephone number, and theelectronic mail address of the Office of the Managed Care Ombudsmanestablished pursuant to § 38.2-5904 and shall also specify any requiredlimits imposed by or on behalf of the managed care health insurance plan.Such forms and written procedures shall include a clear and understandabledescription of the covered person's right to appeal adverse decisionspursuant to § 32.1-137.15.
B. The Commissioner, in cooperation with the Bureau of Insurance, shallexamine the complaint system. The effectiveness of the complaint system ofthe managed care health insurance plan licensee in allowing covered persons,or their duly authorized representatives, to have issues regarding quality ofcare appropriately resolved under this article shall be assessed by the StateHealth Commissioner under this article. Compliance by the health carrier andits managed care health insurance plans with the terms and procedures of thecomplaint system, as well as the provisions of Title 38.2, shall be assessedby the Bureau of Insurance.
C. As part of the renewal of a certificate, each managed care healthinsurance plan licensee shall submit to the Commissioner and to the Office ofthe Managed Care Ombudsman an annual complaint report in a form agreed andprescribed by the Board and the Bureau of Insurance. The complaint reportshall include, but shall not be limited to (i) a description of theprocedures of the complaint system, (ii) the total number of complaintshandled through the complaint system, (iii) the disposition of thecomplaints, (iv) a compilation of the nature and causes underlying thecomplaints filed, (v) the time it took to process and resolve each complaint,and (vi) the number, amount, and disposition of malpractice claimsadjudicated during the year with respect to any of the managed care healthinsurance plan's health care providers.
The Department of Human Resource Management and the Department of MedicalAssistance Services shall file similar periodic reports with theCommissioner, in a form prescribed by the Board, providing appropriateinformation on all complaints received concerning quality of care andutilization review under their respective health benefits program and managedcare health insurance plan licensee contractors.
D. The Commissioner shall examine the complaint system under subsection B forcompliance of the complaint system with respect to quality of care and shallrequire corrections or modifications as deemed necessary.
E. The Commissioner shall have no jurisdiction to adjudicate individualcontroversies arising under this article.
F. The Commissioner of Health or the nonprofit organization pursuant to §32.1-276.4 may prepare a summary of the information submitted pursuant tothis provision and § 32.1-122.10:01 to be included in the patient level database.
(1998, cc. 744, 891; 1999, cc. 643, 649; 2000, cc. 66, 657, 922.)