§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]