§432E-5  Complaints and appeals procedurefor enrollees.  (a)  A managed care plan with enrollees in this State shallestablish and maintain a procedure to provide for the resolution of anenrollee's complaints and appeals.  The procedure shall provide for expeditedappeals under section 432E-6.5.  The definition of medical necessity in section432E-1.4 shall apply in a managed care plan's complaints and appealsprocedures.

(b)  The managed care plan shall at all timesmake available its complaints and appeals procedures.  The complaints andappeals procedures shall be reasonably understandable to the average laypersonand shall be provided in a language other than English upon request.

(c)  A managed care plan shall decide anyexpedited appeal as soon as possible after receipt of the complaint, takinginto account the medical exigencies of the case, but not later than seventy-twohours after receipt of the request for expedited appeal.

(d)  A managed care plan shall send notice ofits final internal determination within sixty days of the submission of thecomplaint to the enrollee, the enrollee's appointed representative, ifapplicable, the enrollee's treating provider, and the commissioner.  The noticeshall include the following information regarding the enrollee's rights andprocedures:

(1)  The enrollee's right to request an externalreview;

(2)  The sixty-day deadline for requesting theexternal review;

(3)  Instructions on how to request an externalreview; and

(4)  Where to submit the request for an externalreview. [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]