28 Tex. Admin. Code § 10.121 - Complaints; Deadlines for Response and Resolution

(a) Not later than seven calendar days after receipt of an oral or written complaint, a network must:

(1) acknowledge receipt of the complaint in writing;

(2) acknowledge the date of receipt; and

(3) provide a description of the network's complaint procedures and deadlines.

(b) A network must investigate each oral or written complaint received in accordance with the network's policies and in compliance with this subchapter.

(c) After a network has investigated a complaint, the network must issue a resolution letter to the complainant not later than the 30th calendar day after the network receives the written complaint that:

(1) explains the network's resolution of the complaint;

(2) states the specific reasons for the resolution;

(3) states the specialization of any health care provider consulted;

(4) explains the network's procedures and deadlines for filing an appeal of the complaint; and

(5) states that, if the complainant is dissatisfied with the resolution of the complaint or the complaint process, the complainant may file a complaint with the department as described in § 10.122 of this title (relating to Submitting Complaints to the Department).

(d) A network must maintain a complaint-and-appeal log regarding each complaint and categorize each complaint and appeal as one or more of the following:

(1) quality of care or services;

(2) accessibility and availability of services or providers;

(3) utilization review;

(4) complaint procedures;

(5) health care provider contracts;

(6) bill payment, as applicable;

(7) fee disputes; and

(8) miscellaneous.

(e) Each network must maintain the complaint-and-appeal log required under subsection (d) of this section and documentation on each complaint, appeal, complaint proceeding, and action taken on the complaint until the third anniversary after the date the complaint was received.

Notes

28 Tex. Admin. Code § 10.121

The provisions of this §10.121 adopted to be effective December 5, 2005, 30 TexReg 8099; The provisions of this §10.121 adopted to be effective December 5, 2005, 30 TexReg 8099; Amended by Texas Register, Volume 47, Number 30, July 29, 2022, TexReg 4555, eff. 8/2/2022