§ 19-705.2. Complaints of members and subscribers.
(a) Complaint system - Establishment.- With the advice of the Secretary, the Commissioner shall adopt regulations to establish a system for the receipt and timely investigation of complaints of members and subscribers of health maintenance organizations concerning the operation of any health maintenance organization in this State.
(b) Complaint system - Contents and included procedures.- The complaint system shall include:
(1) A procedure for the timely acknowledgment of receipt of a complaint;
(2) Criteria that the Secretary shall adopt by regulation for determining the appropriate level of investigation for a complaint concerning quality of care, including:
(i) A determination as to whether the member or subscriber with the complaint previously attempted to have the complaint resolved; and
(ii) A determination as to whether a complaint should be sent to the member's or subscriber's health maintenance organization for resolution prior to investigation under the provisions of this section; and
(3) A procedure for the referral of quality of care complaints to the Secretary for an appropriate investigation.
(c) Investigations.- If a determination is made to investigate a complaint under the provisions of this section prior to the member or subscriber attempting to otherwise resolve the complaint, the reasons for that determination shall be documented.
(d) Notice of establishment of system.- Notice of the complaint system established under the provisions of this section shall be included in all contracts between a health maintenance organization and a member or subscriber of a health maintenance organization.
(e) Reports on investigations.- For quality of care complaints referred to the Secretary for investigation under subsection (b) (3) of this section, the Secretary shall report to the Commissioner in a timely manner on the results and findings of each investigation.
§ 19-705.2. Complaints of members and subscribers.
(a) Complaint system - Establishment.- With the advice of the Secretary, the Commissioner shall adopt regulations to establish a system for the receipt and timely investigation of complaints of members and subscribers of health maintenance organizations concerning the operation of any health maintenance organization in this State.
(b) Complaint system - Contents and included procedures.- The complaint system shall include:
(1) A procedure for the timely acknowledgment of receipt of a complaint;
(2) Criteria that the Secretary shall adopt by regulation for determining the appropriate level of investigation for a complaint concerning quality of care, including:
(i) A determination as to whether the member or subscriber with the complaint previously attempted to have the complaint resolved; and
(ii) A determination as to whether a complaint should be sent to the member's or subscriber's health maintenance organization for resolution prior to investigation under the provisions of this section; and
(3) A procedure for the referral of quality of care complaints to the Secretary for an appropriate investigation.
(c) Investigations.- If a determination is made to investigate a complaint under the provisions of this section prior to the member or subscriber attempting to otherwise resolve the complaint, the reasons for that determination shall be documented.
(d) Notice of establishment of system.- Notice of the complaint system established under the provisions of this section shall be included in all contracts between a health maintenance organization and a member or subscriber of a health maintenance organization.
(e) Reports on investigations.- For quality of care complaints referred to the Secretary for investigation under subsection (b) (3) of this section, the Secretary shall report to the Commissioner in a timely manner on the results and findings of each investigation.
§ 19-705.2. Complaints of members and subscribers.
(a) Complaint system - Establishment.- With the advice of the Secretary, the Commissioner shall adopt regulations to establish a system for the receipt and timely investigation of complaints of members and subscribers of health maintenance organizations concerning the operation of any health maintenance organization in this State.
(b) Complaint system - Contents and included procedures.- The complaint system shall include:
(1) A procedure for the timely acknowledgment of receipt of a complaint;
(2) Criteria that the Secretary shall adopt by regulation for determining the appropriate level of investigation for a complaint concerning quality of care, including:
(i) A determination as to whether the member or subscriber with the complaint previously attempted to have the complaint resolved; and
(ii) A determination as to whether a complaint should be sent to the member's or subscriber's health maintenance organization for resolution prior to investigation under the provisions of this section; and
(3) A procedure for the referral of quality of care complaints to the Secretary for an appropriate investigation.
(c) Investigations.- If a determination is made to investigate a complaint under the provisions of this section prior to the member or subscriber attempting to otherwise resolve the complaint, the reasons for that determination shall be documented.
(d) Notice of establishment of system.- Notice of the complaint system established under the provisions of this section shall be included in all contracts between a health maintenance organization and a member or subscriber of a health maintenance organization.
(e) Reports on investigations.- For quality of care complaints referred to the Secretary for investigation under subsection (b) (3) of this section, the Secretary shall report to the Commissioner in a timely manner on the results and findings of each investigation.
