44-7309 Second-level grievance review. - Nebraska Statutes

44-7309. Second-level grievance review.(1) A health carrier that offers managed care plans shall establish a second-level grievance review process for its managed care plans to give those covered persons who are dissatisfied with the first-level grievance review decision the option to request a second-level review, at which the covered person has the right to appear in person before authorized representatives of the health carrier. A health carrier required by this section to establish a second-level grievance review process shall provide covered persons with adequate notice of that option.(2)(a) With respect to a second-level review of a grievance, a health carrier shall appoint a second-level grievance review panel. A majority of the panel shall be comprised of persons who were not previously involved in the grievance. The panel shall have the legal authority to bind the health carrier to the panel's decision.(b) A health carrier shall ensure that a majority of the persons reviewing a grievance involving an adverse determination are health care professionals who have appropriate expertise.(3) A health carrier's procedures for conducting a second-level panel review shall include the following:(a) The review panel shall schedule and hold a review meeting within forty-five working days after receiving a request from a covered person for a second-level review. In cases in which the covered person cannot appear in person, a health carrier shall offer the covered person the opportunity to communicate with the review panel by conference call or other available technology;(b) Upon the request of a covered person, a health carrier shall provide to the covered person all relevant information that is not confidential or privileged;(c) A covered person has the right to:(i) Attend the second-level review;(ii) Present his or her cases to the review panel;(iii) Submit supporting material both before and at the review meeting;(iv) Ask questions of any representative of the health carrier; and(v) Be assisted or represented by a person of his of her choice;(d) The notice shall advise the covered person of the rights specified in subdivision (3)(c) of this section;(e) The review shall include (i) documentation of the substance of the grievance and (ii) full investigation of the substance of the grievance, including all known aspects of clinical care involved; and(f) The review panel shall issue a written decision to the covered person within five working days after completing the review meeting. SourceLaws 1998, LB 1162, § 74.