Sec. 38a-478m. Internal grievance procedure. Notice re procedure and final resolution. Penalties. Fines allocated to Office of the Healthcare Advocate. - Connecticut Statutes

      Sec. 38a-478m. Internal grievance procedure. Notice re procedure and final resolution. Penalties. Fines allocated to Office of the Healthcare Advocate. (a) Each managed care organization or health insurer, as defined in section 38a-478n, shall establish and maintain an internal grievance procedure to assure that enrollees, as defined in section 38a-478n, may seek a review of any grievance that may arise from a managed care organization's or health insurer's action or inaction, other than action or inaction based on utilization review, and obtain a timely resolution of any such grievance. Such grievance procedure shall comply with the following requirements:

      (1) Enrollees shall be informed of the grievance procedure at the time of initial enrollment and at not less than annual intervals thereafter, which notification may be met by inclusion in an enrollment agreement or update. Each enrollee and the enrollee's provider shall also be informed of the grievance procedure when a decision has been made not to certify an admission, service or extension of stay ordered by the provider.

      (2) Notices to enrollees and providers describing the grievance procedure shall explain: (A) The process for filing a grievance with the managed care organization or health insurer, which may be communicated orally, electronically or in writing; (B) that the enrollee, or a person acting on behalf of an enrollee, including the enrollee's health care provider, may make a request for review of a grievance; and (C) the time periods within which the managed care organization or health insurer must resolve the grievance.

      (3) Each managed care organization and health insurer shall notify its enrollee in writing in cases where an appeal to reverse a denial of a claim based on medical necessity is unsuccessful. Each notice of a final denial of a claim based on medical necessity shall include (A) a written statement that all internal appeal mechanisms have been exhausted, and (B) a copy of the application and procedures prescribed by the commissioner for filing an appeal to the commissioner pursuant to section 38a-478n.

      (b) All reviews conducted under this section shall be resolved not later than sixty days from the date the enrollee or person acting on behalf of the enrollee commences the complaint, unless an extension is requested by the enrollee or person acting on behalf of the enrollee.

      (c) A managed care organization that fails to provide notice of the resolution of a complaint within the time provided in subsection (b) of this section shall be fined twenty-five dollars for each failure to provide notice. Any fines collected under this section shall be paid to the Insurance Commissioner and deposited in the Insurance Fund established in section 38a-52a. The amount of such fines shall be allocated to the Office of the Healthcare Advocate for the purposes set forth in section 38a-1041.

      (P.A. 97-99, S. 14; P.A. 99-284, S. 35; P.A. 05-94, S. 2; 05-97, S. 1.)

      History: P.A. 99-284 designated existing provisions as Subsec. (a), amending Subdiv. (1) by requiring enrollees to be informed of the grievance procedure and amending Subdiv. (2) by allowing other forms of communication, and added new Subsec. (b) re reviews within 60 days; P.A. 05-94 amended Subsec. (a) to reference health insurers and add Subdiv. (3) re written notice to an enrollee when an appeal of claim based on medical necessity is unsuccessful, effective July 1, 2005; P.A. 05-97 amended Subsec. (a) to reference providers and, in Subdiv. (2)(B) insert "or", amended Subsec. (b) to reference a "person acting on behalf of the enrollee", and added new Subsec. (c) to add a $25 fine for failure to provide notice of resolution of complaints and allocate fines to the Office of Managed Care Ombudsman (Revisor's note: Pursuant to P.A. 05-102, "Office of Managed Care Ombudsmen" was changed editorially by the Revisors to "Office of the Healthcare Advocate").