376.1385. Second-level review procedures. - Missouri Statutes

State Codes and Statutes

Statutes > Missouri > T24 > C376 > 376_1385

Second-level review procedures.

376.1385. 1. Upon receipt of a request for second-level review, ahealth carrier shall submit the grievance to a grievance advisory panelconsisting of:

(1) Other enrollees;

(2) Representatives of the health carrier that were not involved inthe circumstances giving rise to the grievance or in any subsequentinvestigation or determination of the grievance; and

(3) Where the grievance involves an adverse determination, a majorityof persons that are appropriate clinical peers in the same or similarspecialty as would typically manage the case being reviewed that were notinvolved in the circumstances giving rise to the grievance or in anysubsequent investigation or determination of the grievance.

2. Review by the grievance advisory panel shall follow the same timeframes as a first level review, except as provided for in section 376.1389if applicable. Any decision of the grievance advisory panel shall includenotice of the enrollee's or the health carrier's or plan sponsor's rightsto file an appeal with the director's office of the grievance advisorypanel's decision. The notice shall contain the toll-free telephone numberand address of the director's office.

(L. 1997 H.B. 335)

State Codes and Statutes

Statutes > Missouri > T24 > C376 > 376_1385

Second-level review procedures.

376.1385. 1. Upon receipt of a request for second-level review, ahealth carrier shall submit the grievance to a grievance advisory panelconsisting of:

(1) Other enrollees;

(2) Representatives of the health carrier that were not involved inthe circumstances giving rise to the grievance or in any subsequentinvestigation or determination of the grievance; and

(3) Where the grievance involves an adverse determination, a majorityof persons that are appropriate clinical peers in the same or similarspecialty as would typically manage the case being reviewed that were notinvolved in the circumstances giving rise to the grievance or in anysubsequent investigation or determination of the grievance.

2. Review by the grievance advisory panel shall follow the same timeframes as a first level review, except as provided for in section 376.1389if applicable. Any decision of the grievance advisory panel shall includenotice of the enrollee's or the health carrier's or plan sponsor's rightsto file an appeal with the director's office of the grievance advisorypanel's decision. The notice shall contain the toll-free telephone numberand address of the director's office.

(L. 1997 H.B. 335)

State Codes and Statutes

Back To Homepage

State Codes and Statutes

Statutes > Missouri > T24 > C376 > 376_1385

Second-level review procedures.

376.1385. 1. Upon receipt of a request for second-level review, ahealth carrier shall submit the grievance to a grievance advisory panelconsisting of:

(1) Other enrollees;

(2) Representatives of the health carrier that were not involved inthe circumstances giving rise to the grievance or in any subsequentinvestigation or determination of the grievance; and

(3) Where the grievance involves an adverse determination, a majorityof persons that are appropriate clinical peers in the same or similarspecialty as would typically manage the case being reviewed that were notinvolved in the circumstances giving rise to the grievance or in anysubsequent investigation or determination of the grievance.

2. Review by the grievance advisory panel shall follow the same timeframes as a first level review, except as provided for in section 376.1389if applicable. Any decision of the grievance advisory panel shall includenotice of the enrollee's or the health carrier's or plan sponsor's rightsto file an appeal with the director's office of the grievance advisorypanel's decision. The notice shall contain the toll-free telephone numberand address of the director's office.

(L. 1997 H.B. 335)