§ 9.703. Internal complaint process.

 (a)  A plan shall establish, operate and maintain an internal complaint process which meets the requirements of section 2141 of the act (40 P. S. §  991.2141), and this subchapter. The process shall address how an enrollee or the enrollee’s representative may file complaints by which the enrollee or the enrollee’s representative seek to have the plan review and change plan decisions regarding participating health care providers, or the health plan coverage, plan operations and management policies of the plan.

 (b)  A plan shall permit an enrollee or the enrollee’s representative to file with it a written or oral complaint.

 (c)  A plan’s internal complaint process shall include the following standards:

   (1)  First level review.

     (i)   Upon receipt of the complaint, the plan shall provide written confirmation of its receipt to the enrollee and the enrollee’s representative, if the enrollee has designated one, including the following information:

       (A)   That the plan considers the matter to be a complaint, and that the enrollee or the enrollee’s representative may question this classification by contacting the Department.

       (B)   That the enrollee may appoint a representative to act on the enrollee’s behalf at any time during the process.

       (C)   That the enrollee or the enrollee’s representative may review information related to the complaint upon request and submit additional material to be considered by the plan.

       (D)   That the enrollee or the enrollee’s representative may request the aid of a plan employee who has not participated in previous decisions to deny coverage for the issue in dispute, at no charge, in preparing the enrollee’s complaint.

       (E)   If the plan chooses to permit attendance at the first level review, that the enrollee and the enrollee’s representative may attend the first level review.

     (ii)   The first level complaint review shall be performed by an initial review committee which shall include one or more employees of the plan. The members of the committee may not have been involved in a prior decision to deny the enrollee’s complaint.

     (iii)   A plan shall provide the enrollee and the enrollee’s representative access to all information relating to the matter being complained of and shall permit an enrollee to provide written data or other material in support of the complaint. The plan may charge a reasonable fee for reproduction of documents.

     (iv)   The plan shall provide, at no charge, at the request of the enrollee or the enrollee’s representative, a plan employee who has not participated in previous decisions to deny coverage for the issue in dispute, to aid the enrollee or the enrollee’s representative in preparing the enrollee’s first level complaint.

     (v)   The plan shall complete its review and investigation of the complaint and shall arrive at its decision within 30 days of receipt of the complaint.

     (vi)   The plan shall notify the enrollee in writing of the decision of the initial review committee within 5 business days of the committee’s decision. The notice to the enrollee and the enrollee’s representative shall include the basis for the decision and the procedures to file a request for a second level review of the decision of the initial review committee including:

       (A)   A statement of the issue reviewed by the first level review committee.

       (B)   The specific reasons for the decision.

       (C)   References to the specific plan provisions on which the decision is based.

       (D)   If an internal rule, guideline, protocol, or other similar criterion was relied on in making the decision, either the specific rule, guideline, protocol or criterion, or instructions on how to obtain the internal rule, guideline, protocol or criterion.

       (E)   An explanation of how to request a second level review of the decision of the initial review committee.

       (F)   The time frames for requesting a second level review, if any. See §  9.702(d)(1) (relating to complaints and grievances).

   (2)  Second level review.

     (i)   Upon receipt of the request for the second level review, the plan shall send the enrollee and the enrollee’s representative an explanation of the procedures to be followed during the second level review. This information shall include the following:

       (A)   A statement that, and an explanation of how, the enrollee or the enrollee’s representative may request the aid of a plan employee at no charge, who has not participated in previous decisions to deny coverage for the issue in dispute, in preparing the enrollee’s second level complaint.

       (B)   Notification that the enrollee and the enrollee’s representative have the right to appear before the second level review committee and that the plan will provide the enrollee and the enrollee’s representative with 15 days advance written notice of the time scheduled for that review.

     (ii)   The second level complaint review shall be performed by a second level review committee made up of three or more individuals who did not participate in the matter under review.

       (A)   At least one third of the second level review committee may not be employees of the plan or of a related subsidiary or affiliate.

       (B)   The members of the second level review committee shall have the duty to be impartial in the committee’s review and decision.

     (iii)   The second level review shall satisfy the following:

       (A)   The enrollee or the enrollee’s representative, or both, shall have the right to be present at the second level review.

       (B)   The plan shall notify the enrollee and the enrollee’s representative at least 15 days in advance of the date scheduled for the second level review.

       (C)   The plan shall provide reasonable flexibility in terms of time and travel distance when scheduling a second level review to facilitate the attendance of the enrollee and the enrollee’s representative. The plan shall make reasonable accommodation to facilitate the participation of the enrollee and the enrollee’s representative by conference call or in person and shall take into account the enrollee’s and the enrollee’s reresentative’s access to transportion and any disabilities that may impede or limit the enrollee’s ability to travel.

       (D)   If an enrollee cannot appear in person at the second level review, the plan shall provide the enrollee the opportunity to communicate with the review committee by telephone or other appropriate means.

       (E)   Attendance at the second level review shall be limited to members of the review committee; the enrollee or the enrollee’s representatives, including any legal representative or attendant necessary for the enrollee to participate in or understand the proceedings, or both; the enrollee’s provider if the enrollee consents to the provider being present; applicable witnesses; and appropriate representatives of the plan. Persons attending the second level review and their respective roles at the review shall be identified for the enrollee.

       (F)   The plan shall provide, at no charge, at the request of the enrollee, or the enrollee’s representative, a plan employee, who has not participated in previous decisions to deny coverage for the issue in dispute, to aid the enrollee or the enrollee’s representative in preparing the enrollee’s second level complaint.

       (G)   Committee proceedings at the second level review shall be informal and impartial to avoid intimidating the enrollee or the enrollee’s representative.

       (H)   The committee may not discuss the case to be reviewed prior to the second level review meeting.

       (I)   A committee member who does not personally attend the review meeting may not vote on the case unless that person actively participates in the review meeting by telephone or videoconference, and has the opportunity to review any additional information introduced at the review meeting prior to the vote.

       (J)   The plan may provide an attorney to represent the interests of the committee and to ensure the fundamental fairness of the review and that all disputed issues are adequately addressed. In the scope of the attorney’s representation of the committee, the attorney representing the committee may not argue the plan’s position, or represent the plan or plan staff.

       (K)   The committee may question the enrollee, the enrollee’s representative and plan staff representing the plan’s position.

       (L)   The committee shall base its decision solely upon the materials and testimony presented at the review meeting.

     (iv)   The proceedings of the second level review committee, including the enrollee’s comments or the comments of the enrollee’s representative, shall be either transcribed verbatim, summarized, or recorded electronically, and maintained as a part of the complaint record to be forwarded to the Department or the Insurance Department upon appeal to either agency.

     (v)   The plan shall complete the second level review and arrive at a decision within 45 days of the plan’s receipt of the request of the enrollee or the enrollee’s representative for a second level review.

     (vi)   The plan shall notify the enrollee and the enrollee’s representative, if any, of the decision of the second level review committee in writing, within 5 business days after the committee’s decision.

     (vii)   The plan shall include in its notice to the enrollee the basis for the decision and the procedures to file an appeal to the Department or the Insurance Department, including the addresses and telephone numbers of both agencies which shall include the following information:

       (A)   A statement of the issue reviewed by the second level review committee.

       (B)   The specific reason or reasons for the decision.

       (C)   References to the specific plan provisions on which the decision is based.

       (D)   If an internal rule, guideline, protocol, or other similar criterion was relied on in making the decision, either the specific rule, guideline, protocol or criterion, or instructions on how to obtain the internal rule, guideline, protocol or criterion.

       (E)   An explanation of how to appeal to the Department or the Insurance Department, including the addresses and telephone numbers of both agencies and the time frames for appealing to the agencies included in §  9.704 (relating to appeal of a complaint decision) and 31 Pa. Code §  154.17 (relating to complaints).

 (d)  The Department of Health address for purposes of this section is: Bureau of Managed Care, Pennsylvania Department of Health, Post Office Box 90, Harrisburg, Pennsylvania 17108, (717) 787-5193. Toll free (888) 466-2787, fax number: (717) 705-0947, or the Pennsylvania AT&T relay service at (800) 654-5984. The Department may change this address upon prior notification in the Pennsylvania Bulletin.



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