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007.05.1-XVI. COMPLAINT/GRIEVANCE SYSTEM.

AR ADC 007.05.1-XVIArkansas Administrative Code

West's Arkansas Administrative Code
Title 007. Department of Health
Division 05. Health Facility Services
Rule 1. Rules and Regulations for Health Maintenance Organizations in Arkansas
Ark. Admin. Code 007.05.1-XVI
007.05.1-XVI. COMPLAINT/GRIEVANCE SYSTEM.
Currentness
A. Each HMO shall establish and maintain a complaint/grievance system approved by the Commissioner, after consultation with the Director, to provide reasonable procedures for the resolution of complaints and grievances initiated by Enrollees concerning Health Care Services.
B. Each HMO shall provide a designated position/title with a designated telephone number and address for receiving oral and written complaints and inquiries concerning complaints and for assisting the Enrollee.
1. Oral complaints and inquiries regarding complaints shall be entered into a written or automated record.
2. Enrollees with complaints which are not resolved shall be informed of the written grievance procedure. Any oral complaint which cannot be resolved informally shall be presented in writing before it can be considered a formal grievance.
C. Each HMO shall have a written grievance procedure for prompt and effective resolution of Enrollee grievances. The grievance procedure shall include, as a minimum, assisting the Enrollee with filing the grievance and the following elements:
1. There shall be an initial level of investigation and review of any grievance;
2. The initial review shall provide the opportunity for the Enrollee and any other party of interest to present data pertinent to the grievance;
3. The decision of the initial review shall be binding unless the Enrollee appeals the decision in writing;
4. The Enrollee shall be notified in writing of the decisions. If the outcome is adverse to the Enrollee, the written notice shall include specific findings related to the grievance, the reason(s) for denial, and the right of the Enrollee to appeal to a second level.
D. An Enrollee shall have the right to appeal a decision of the initial review to a second level review committee.
1. The second level of review shall be conducted by a committee established by the HMO.
2. The second level review committee shall have written procedures for investigating grievances and for utilizing informed consultants to resolve grievances.
3. The Enrollee shall be notified in writing of the decision of the second level review. If the outcome is adverse to the Enrollee, the written notice shall include the specific findings Related to the decision, the reason(s) for denial, and the right of the Enrollee to appeal the decision of the second level review committee to the Commissioner or Director.
E. The HMO shall specify time limits for receipt and disposition of grievances at each level of review. The time frame for each level shall not exceed thirty (30) days unless the HMO provides documentation for justification of a longer time frame.
F. The HMO shall include a description of the complaint/grievance system in the Enrollee Evidence of Coverage.
G. At any stage of the grievance process, at the request of the Enrollee, the HMO may appoint a member of its staff, who has no direct involvement in the case, to assist the Enrollee. An Enrollee presenting a grievance shall be specifically notified of his/her right to have such a staff member appointed for assistance.
H. Each HMO shall submit to the Commissioner and the Director an annual report which shall include:
1. A description of the procedures of such grievance/appeals system;
2. The total number of grievances/appeals handled through such grievance/appeals system and a compilation of the causes underlying those filed;
3. For a Staff Model HMO, the number, amount, and disposition of malpractice claims settled during the year by the HMO and any of the Providers utilized by it;
4. A summary of the disposition of grievances/appeals; (the copy to the Director shall also include a summary of the processing times as an addendum), and
5. Any such other information as reasonably required by the Commissioner or Director pursuant to these Rules and Regulations.
I. The Commissioner or Director may examine such grievance/appeals system subject to limitations concerning medical records of Enrollees.
J. The Director shall investigate each complaint filed with the Department concerning Health Care Services of an HMO or its Providers.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.05.1-XVI, AR ADC 007.05.1-XVI
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