Section 13: Formal internal grievance process; expedited resolution policy
Section 13. (a) A carrier or utilization review organization shall maintain a formal internal grievance process that is compliant with the Patient Protection and Affordable Care Act, Public Law 111–148, as amended, as well as with any rules, regulations or guidance applicable thereto, and such formal internal grievance process shall provide for adequate consideration and timely resolution of grievances, which shall include but not be limited to: (i) a system for maintaining records of each grievance filed by an insured or on the insured's behalf, and responses thereto, for a period of 7 years, which records shall be subject to inspection by the commissioner; (ii) the provision of a clear, concise and complete description of the carrier's formal internal grievance process and the procedures for obtaining external review pursuant to section 14 with each notice of an adverse determination; (iii) the carrier's toll-free telephone number for assisting insureds in resolving such grievances and the consumer assistance toll-free telephone number maintained by the office of patient protection; (iv) a written acknowledgement of the receipt of a grievance within 15 days and a written resolution of each grievance sent to the insured by certified or registered mail, or other express carrier with proof of delivery, within 30 days from receipt thereof; (v) a procedure to accept grievances by telephone, in person, by mail and by electronic means; (vi) a process for an insured to request the appointment of an authorized representative to act on the insured's behalf; and (vii) a procedure to accept an insured's request for medical release forms by electronic means, which shall include delivery to a designated email address or access to an online consumer portal accessible by the insured, the insured's family member or the insured's authorized representative who can provide the insured's membership identification number. The time limits established by this paragraph may be waived or extended by mutual agreement of the insured and the carrier.
(b) The formal internal grievance process maintained by a carrier or utilization review organization shall provide for an expedited resolution of a grievance concerning a carrier's coverage or provision of immediate and urgently needed services. Said expedited resolution policy shall include, but not be limited to:
(i) a resolution before an insured's discharge from a hospital if the grievance is submitted by an insured who is an inpatient in a hospital;
(ii) provisions for the automatic reversal of decisions denying coverage for services or durable medical equipment, pending the outcome of the appeals process, within 48 hours, or earlier for durable medical equipment at the option of the physician responsible for treatment or proposed treatment of the covered patient, of receipt of certification by said physician that, in the physician's opinion, the service or use of durable medical equipment at issue in a grievance or appeal is medically necessary, that a denial of coverage for such services or durable medical equipment would create a substantial risk of serious harm to the patient, and that the risk of that harm is so immediate that the provision of such services or durable medical equipment should not await the outcome of the normal appeal or grievance process, but, in the event said physician exercises the option of automatic reversal earlier than 48 hours for durable medical equipment, he must further certify as to the specific, immediate and severe harm that will result to the patient absent action within the 48 hour time period;
(iii) a resolution within 5 days from the receipt of such grievance if submitted by an insured with a terminal illness; and
(iv) a resolution of a claim involving urgently needed services within 72 hours.
If the expedited review process affirms the denial of coverage or treatment, the carrier shall provide the insured, within 2 business days of the decision, including by any electronic means consented to by the insured: (1) a statement setting forth the specific medical and scientific reasons for denying coverage or treatment; (2) a description of alternative treatment, services or supplies covered or provided by the carrier, if any; (3) a description of the insured's rights to any further appeal; and (4) a description of the insured's right to request a conference. The carrier or utilization review organization shall schedule such a conference within ten days of receiving such a request from an insured, at which the information provided to the insured pursuant to clauses (1) and (2) shall be reviewed by the insured and a representative of the carrier who has authority to determine the disposition of the grievance. The carrier shall permit attendance at the conference of the insured, a designee of the insured or both, or, if the insured is a minor or incompetent, the parent, guardian or conservator of the insured as appropriate. The conference required by this paragraph shall be held within five business days if the treating physician determines, after consultation with the carrier's medical director or his designee, and based on standard medical practice, that the effectiveness of either the proposed treatment, services or supplies or any alternative treatment, services or supplies covered by the carrier, would be materially reduced if not provided at the earliest possible date.
(c) A grievance not properly acted on by the carrier within the time limits required by this section shall be deemed resolved in favor of the insured. Notwithstanding the exhaustion of formal internal grievance process remedies required by section 14, in the event that an insured claims that a carrier failed to properly act on a grievance that is an adverse determination within the time limits required by this section, such claim is immediately eligible for external review. The external review of a grievance under section 14 shall be decided in favor of the insured unless the carrier provides substantial evidence, such as proof of delivery, that the carrier properly complied with the time limits required under this section.
(d) An insured may request an expedited review of a grievance and at the same time may request an expedited external review of the grievance pursuant to section 14.