441—88.8 (249A) Grievance procedures.
	 88.8(1) Written procedure. The HMO must have a written procedure by which enrolled recipients may express grievances, complaints, concerns, or recommendations, either individually or as a class and which:
	  a.   	 Is approved by the department prior to use.
	  b.   	 Acknowledges receipt of a grievance to the grievant.
	  c.   	 Sets time frames for resolution including emergency procedures which are appropriate to the nature of the grievance and which require that all grievances shall be resolved within 30 days.
	  d.   	 Ensures the participation of persons with authority to require corrective action.
	  e.   	 Includes at least one level of appeal.
	  f.   	 Ensures the confidentiality of the grievant.
	  g.   	 Ensures issuance of a departmentally approved notice of decision for each adverse action and for each decision on requests for HMO reconsideration. These notices shall contain the enrollee’s appeal rights with the department and shall contain an adequate explanation of the action taken and the reason for the decision.
	 88.8(2) Written record. All grievances, including informal or verbal complaints, which must be referred or researched for resolution must be recorded in writing. A log of the grievances must be maintained and made available at the time of audit and must include progress notes and resolutions.
	 88.8(3) Information concerning grievance procedures. The HMO’s written grievance procedure must be provided to each newly covered recipient not later than the effective date of coverage.
	 88.8(4) Appeals to the department. A recipient shall exhaust the established grievance procedure of the HMO before appealing the issue to the department under the provisions of 441—Chapter 7. The HMO appeal process shall not be more stringent in requirements and time frames than the department’s appeal process. The HMO shall issue a written notice stating the outcome of all appeals.
	 88.8(5) Periodic report to the department. The HMO must make quarterly reports to the department summarizing grievances and resolutions as specified in the contract.
	 88.8(6) Consent for state fair hearing. Network providers which are contracted and in good standing with a medical managed care organization (MCO) may request a state fair hearing only for disputes regarding payment of claims, specifically, disputes concerning the denial of a claim or reduction in payment, and only when acting on behalf of the member. The network provider requesting such a state fair hearing must have the prior, express, signed written consent of the member or the member’s lawfully appointed guardian in order to request such a hearing. Notwithstanding any contrary provision in 441—Chapter 7, no state fair hearing will be granted unless the network provider submits a document providing such member’s approval of the request for a state fair hearing. The document must specifically inform the member that protected health information (PHI) may be discussed at the hearing and may be made public in the course of the hearing and subsequent administrative and judicial proceedings. The document must contain language that indicates the member’s knowledge of the potential for PHI to become public and that the member knowingly, voluntarily and intelligently consents to the network provider’s bringing the state fair hearing on the member’s behalf.
[ARC 0583C, IAB 2/6/13, effective 4/1/13]