1 Tex. Admin. Code § 353.415 - Member Complaint and Appeal Procedures
(a) Managed care organizations (MCOs) must
develop and maintain a system and process for taking, tracking, reviewing, and
reporting member complaints and appeals.
(b) MCOs must establish and maintain internal
procedures for the resolution of member complaints and appeals. The procedures
must be in writing. The procedures must be detailed and specific regarding how
complaints and appeals are to be taken, to whom complaints are referred, and by
when a complaint must be resolved.
(c) MCOs must establish a procedure to assist
members in understanding and using the MCO's internal complaint and appeal
process. The member's complaint and appeal procedure must be:
(1) in writing and distributed to each member
upon enrollment;
(2) provided to
the member each time the member's benefits are reduced, denied, or terminated
for any reason;
(3) easy for
members to understand and follow; and
(4) contain a prominent notice to the member
that complies with the fair hearing rules found in Chapter 357, Subchapter A of
this title (relating to Uniform Fair Hearing Rules), stating the member retains
all rights as a Medicaid client to a fair hearing through the Health and Human
Services Commission (HHSC), in addition to the MCO's complaint and appeal
process.
(d) HHSC will
review the MCO's complaint and appeals procedures to determine if they comply
with HHSC's standards before HHSC approves use of the procedures. Reports
containing complaint summaries must be submitted to HHSC in compliance with
HHSC policy.
(e) HHSC retains the
authority to make the final decision following HHSC's fair hearing
process.
Notes
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