38.2-5804 - Complaint system.
§ 38.2-5804. Complaint system.
A. A health carrier subject to subsection B of § 38.2-5801 shall establishand maintain for each of its MCHIPs a complaint system approved by theCommission and the State Health Commissioner to provide reasonable proceduresfor the resolution of written complaints in accordance with requirements inor established pursuant to provisions in this title and Title 32.1 and shallinclude the following:
1. A record of the complaints shall be maintained for no less than five years.
2. Such health carrier shall provide complaint forms and/or writtenprocedures to be given to covered persons who wish to register writtencomplaints. Such forms or procedures shall include the address and telephonenumber of the managed care licensee to which complaints shall be directed andthe mailing address, telephone number, and electronic mail address of theOffice of the Managed Care Ombudsman, and shall also specify any requiredlimits imposed by or on behalf of the MCHIP. Such forms and writtenprocedures shall include a clear and understandable description of thecovered person's right to appeal adverse decisions pursuant to § 32.1-137.15.
B. The Commission, in cooperation with the State Health Commissioner, 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 chapter shall be assessed by the StateHealth Commissioner pursuant to provisions in Title 32.1 and the regulationspromulgated thereunder. Compliance by the health carrier and its managed carehealth insurance plans with the terms and procedures of the complaint system,as well as the provisions of this title, shall be assessed by the Commission.
C. The health carrier for each MCHIP shall submit to the Office of theManaged Care Ombudsman and the State Health Commissioner an annual complaintreport in a form prescribed by the Commission and the Board of Health. Thecomplaint report shall include (i) a description of the procedures of thecomplaint system, (ii) the total number of complaints handled through thegrievance or complaint system, (iii) the disposition of the complaints, (iv)a compilation of the nature and causes underlying the complaints filed, (v)the time it took to process and resolve each complaint, and (vi) the number,amount, and disposition of malpractice claims adjudicated during the yearwith respect to any of the MCHIP's affiliated providers.
D. The provisions of this section shall not apply to plans administered bythe Department of Medical Assistance Services that provide benefits pursuantto Title XIX or Title XXI of the Social Security Act, as amended.
E. The provisions of Chapter 5 (§ 38.2-500 et seq.) of this title shall applyto the health carrier, its MCHIPs, and evidence of coverage andrepresentations thereto, except to the extent that the Commission determinesthat the nature of the health carrier, its MCHIP, and evidences of coverageand representations thereto render any of the provisions clearlyinappropriate.
(1998, c. 891; 1999, cc. 643, 649; 2000, c. 922; 2006, c. 866.)