2006 New York Code - Grievance Procedure.

 
    * § 4408-a*. Grievance procedure. 1. A health maintenance organization
  licensed  pursuant  to  article  forty-three  of  the  insurance  law or
  certified pursuant to this article, and any other organization certified
  pursuant to this  article  shall  establish  and  maintain  a  grievance
  procedure.  Pursuant  to  such procedure, enrollees shall be entitled to
  seek  a  review  of  determinations  by  the  organization  other   than
  determinations  subject  to the provisions of article forty-nine of this
  chapter.
    2. (a) An organization shall provide to all enrollees  written  notice
  of  the  grievance procedure in the member handbook and at any time that
  the organization denies access  to  a  referral  or  determines  that  a
  requested  benefit is not covered pursuant to the terms of the contract;
  provided, however, that nothing herein shall  be  deemed  to  require  a
  health  care  provider  to  provide  such  notice.  In the event that an
  organization denies a service as an adverse determination as defined  in
  article  forty-nine  of  this chapter, the organization shall inform the
  enrollee or the enrollee's designee of the appeal rights provided for in
  article forty-nine of this chapter.
    (b) The notice to an enrollee describing the grievance  process  shall
  explain:  (i)  the process for filing a grievance with the organization;
  (ii) the timeframes within which a grievance determination must be made;
  and (iii) the right of an enrollee to designate a representative to file
  a grievance on behalf of the enrollee.
    (c) The organization shall assure  that  the  grievance  procedure  is
  reasonably accessible to those who do not speak English.
    3. (a) The organization may require an enrollee to file a grievance in
  writing,  by letter or by a grievance form which shall be made available
  by the organization and which shall conform to applicable standards  for
  readability.
    (b)   Notwithstanding   the   provisions  of  paragraph  (a)  of  this
  subdivision, an enrollee may submit  an  oral  grievance  in  connection
  with:  (i)  a  denial  of,  or failure to pay for, a referral; or (ii) a
  determination as to whether a benefit is covered pursuant to  the  terms
  of the enrollee's contract. In connection with the submission of an oral
  grievance,  an organization may require that the enrollee sign a written
  acknowledgment of the grievance prepared by the organization summarizing
  the nature  of  the  grievance.  Such  acknowledgment  shall  be  mailed
  promptly  to the enrollee, who shall sign and return the acknowledgment,
  with any amendments, in order to initiate the grievance.  The  grievance
  acknowledgment  shall  prominently state that the enrollee must sign and
  return the acknowledgment to initiate the grievance. If an  organization
  does  not  require such a signed acknowledgment, an oral grievance shall
  be initiated at the time of the telephone call.
    (c) Upon receipt of a grievance, the organization shall provide notice
  specifying what information must be  provided  to  the  organization  in
  order to render a decision on the grievance.
    (d) (1) An organization shall designate personnel to accept the filing
  of  an  enrollee's  grievance  by toll-free telephone no less than forty
  hours per week during normal business hours and, shall have a  telephone
  system  available  to take calls during other than normal business hours
  and shall respond to all such calls no less than the next  business  day
  after the call was recorded.
    (2)  Notwithstanding  the  provisions  of  subparagraph  one  of  this
  paragraph, an organization may, in the alternative, designate  personnel
  to  accept  the filing of an enrollee's grievance by toll-free telephone
  not less than forty hours per week during normal business hours and,  in
  the  case  of grievances subject to subparagraph (i) of subdivision four
  of this section, on a twenty-four hour a day, seven day a week basis.
    4. Within fifteen business days  of  receipt  of  the  grievance,  the
  organization  shall  provide  written  acknowledgment  of the grievance,
  including the name, address and telephone number of  the  individual  or
  department  designated  by the organization to respond to the grievance.
  All  grievances  shall  be resolved in an expeditious manner, and in any
  event, no more than: (i) forty-eight hours  after  the  receipt  of  all
  necessary information when a delay would significantly increase the risk
  to  an  enrollee's  health;  (ii)  thirty  days after the receipt of all
  necessary  information  in  the  case  of  requests  for  referrals   or
  determinations   concerning  whether  a  requested  benefit  is  covered
  pursuant to the contract; and (iii) forty-five days after the receipt of
  all necessary information in all other instances.
    5. The organization shall designate one or more qualified personnel to
  review the grievance; provided further, that when the grievance pertains
  to clinical matters, the personnel shall include, but not be limited to,
  one or more licensed, certified or registered health care professionals.
    6. The notice of a determination of the grievance  shall  be  made  in
  writing  to the enrollee or to the enrollee's designee. In the case of a
  determination made in conformance with subparagraph (i)  of  subdivision
  four  of this section, notice shall be made by telephone directly to the
  enrollee with written notice to follow within three business days.
    7. The notice of a  determination  shall  include:  (i)  the  detailed
  reasons for the determination; (ii) in cases where the determination has
  a  clinical  basis,  the  clinical  rationale for the determination; and
  (iii) the procedures for the filing of an appeal of  the  determination,
  including a form for the filing of such an appeal.
    8.  An  enrollee  or  an  enrollee's designee shall have not less than
  sixty  business  days  after  receipt  of  notice   of   the   grievance
  determination to file a written appeal, which may be submitted by letter
  or by a form supplied by the organization.
    9.  Within  fifteen  business  days  of  receipt  of  the  appeal, the
  organization  shall  provide  written  acknowledgment  of  the   appeal,
  including  the  name,  address  and  telephone  number of the individual
  designated by the  organization  to  respond  to  the  appeal  and  what
  additional  information,  if  any,  must  be  provided  in order for the
  organization to render a decision.
    10. The determination of an appeal on a clinical matter must  be  made
  by  personnel  qualified  to  review  the  appeal,  including  licensed,
  certified or registered health care professionals who did not  make  the
  initial  determination,  at  least  one  of whom must be a clinical peer
  reviewer  as  defined  in  article  forty-nine  of  this  chapter.   The
  determination  of  an  appeal on a matter which is not clinical shall be
  made by qualified personnel at a higher level  than  the  personnel  who
  made the grievance determination.
    11.  The  organization  shall  seek to resolve all appeals in the most
  expeditious manner and shall make a determination and provide notice  no
  more than:
    (i)  two  business days after the receipt of all necessary information
  when a delay would significantly increase  the  risk  to  an  enrollee's
  health; and
    (ii)   thirty  business  days  after  the  receipt  of  all  necessary
  information in all other instances.
    12. The notice of a determination on an appeal shall include: (i)  the
  detailed  reasons  for  the  determination;  and (ii) in cases where the
  determination has a clinical  basis,  the  clinical  rationale  for  the
  determination.
    13.  An  organization  shall  not retaliate or take any discriminatory
  action against an enrollee because an enrollee has filed a grievance  or
  appeal.
    14.  An  organization  shall  maintain  a  file  on each grievance and
  associated appeal, if any, that shall include the date the grievance was
  filed; a copy of the grievance, if any; the date of  receipt  of  and  a
  copy  of  the  enrollee's  acknowledgment  of the grievance, if any; the
  determination made  by  the  organization  including  the  date  of  the
  determination   and   the   titles  and,  in  the  case  of  a  clinical
  determination, the  credentials  of  the  organization's  personnel  who
  reviewed the grievance. If an enrollee files an appeal of the grievance,
  the file shall include the date and a copy of the enrollee's appeal, the
  determination  made  by  the  organization  including  the  date  of the
  determination  and  the  titles   and,   in   the   case   of   clinical
  determinations,  the  credentials,  of  the organization's personnel who
  reviewed the appeal.
    15. The rights and remedies conferred in this article  upon  enrollees
  shall  be  cumulative  and  in  addition to and not in lieu of any other
  rights or remedies available under law.
    * NB There are 2 § 4408-a's