376.1382. First- and second-level grievance review for managed care plans, first-level procedures. - Missouri Statutes

First- and second-level grievance review for managed care plans,first-level procedures.

376.1382. 1. A health carrier that offers managed care plans shallestablish a first-level and second-level grievance review process for itsmanaged care plans. A grievance may be submitted by an enrollee, anenrollee's representative or a provider acting on behalf of an enrollee.

2. Upon receipt of a request for first-level grievance review, ahealth carrier shall:

(1) Acknowledge receipt in writing of the grievance within tenworking days;

(2) Conduct a complete investigation of the grievance within twentyworking days after receipt of a grievance, unless the investigation cannotbe completed within this time. If the investigation cannot be completedwithin twenty working days after receipt of a grievance, the enrollee shallbe notified in writing on or before the twentieth working day and theinvestigation shall be completed within thirty working days thereafter.The notice shall set forth with specificity the reasons for whichadditional time is needed for the investigation;

(3) Within five working days after the investigation is completed,have someone not involved in the circumstances giving rise to the grievanceor its investigation decide upon the appropriate resolution of thegrievance and notify the enrollee in writing of the health carrier'sdecision regarding the grievance and of the right to file an appeal for asecond-level review. The notice shall explain the resolution of thegrievance and the right to appeal in terms which are clear and specific;

(4) Within fifteen working days after the investigation is completed,notify the person who submitted the grievance of the carrier's resolutionof said grievance.

(L. 1997 H.B. 335)