(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
(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
Table%20of%20Contents%20and%20MCO%20Regulations.docx