Ga. Comp. R. & Regs. R. 120-2-33-.09 - Complaint System
(1)
Each HMO shall establish and maintain a complaint system to provide adequate
and reasonable procedures for expeditious resolution of complaints made by
enrollees concerning any matter related to any provision of such organization's
health services, including, but not limited to, claims regarding the scope of
coverage for health services, denials, cancellations, terminations or renewals
of enrollee coverage, and the quality of health maintenance services
rendered.
(2) The complaint system
shall be organized in a manner that provides meaningful procedures for hearing
and resolving complaints by enrollees. These procedures shall be fully set
forth in group contracts, certificates and individual policies. The complaint
system must be established and approved by the HMO's board of directors. Such
complaint system shall include, but not be limited to:
(a) a definition of a legitimate
complaint;
(b) details on how,
when, where and with whom an enrollee is to file a complaint;
(c) appeals mechanisms and
processes;
(d) the responsibilities
of the various levels of the complaint system and the HMO staff;
(e) a written description of the process for
timely review and disposition of all complaints; and
(f) a written policy about the reasonable
time period for resolving complaints.
(3) These procedures shall also include any
complaint submitted to the HMO by the Department or the Department of Human
Resources as may be received by either Department from enrollees.
(4) If a complaint is made to the Department
or the Department of Human Resources, such Department shall provide a copy of
such complaint to the HMO concerned. The HMO shall provide a written response
to such complaint within ten (10) working days to the complainant, with copies
of such response to the Department and the Department of Human
Resources.
(5) Pursuant to O.C.G.A.
Section 33-21-9, each HMO shall submit for
prior approval by the Commissioner and the Commissioner of Human Resources, and
thereafter maintain, a system for the resolution of complaints. Such complaint
procedures shall be filed in duplicate with the Department and the Department
of Human Resources. In addition, each HMO shall:
(a) submit to the Commissioner and the
Commissioner of Human Resources for prior approval any amendments or proposed
changes to the system by which complaints may be filed and reviewed;
(b) maintain records of each complaint filed
with the HMO for a period of five (5) years, such record to include, but not be
limited to:
1. a copy of the complaint and the
date of its filing;
2. the date and
outcome of all consultations, hearings and hearing findings;
3. the date and decisions of any appeal
proceedings;
4. the date and
proceedings of any litigation; and
5. all letters, documents or evidence
submitted regarding the complaint.
(6) The HMO shall also work with the medical
group, individual practice association, or physicians under contract to promote
the operation of peer review mechanisms internal to those provider
groups.
(7) All enrollees who file
written complaints shall first exhaust the complaint system available under the
HMO. The complaint may then be investigated by the Commissioner or the
Commissioner of Human Resources. The decision whether to investigate any
complaint shall be at the discretion of the Commissioner or the Commissioner of
Human Resources.
Notes
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