| Checklist for MCHIP Complaint,
Grievance, and Appeal System Filings
Each Managed Care Health Insurance Plan
(MCHIP) must establish and maintain a complaint system approved
by the State Corporation Commission, as stated in the Code of
Virginia §38.2-5804.
The Office of the Managed Care Ombudsman is the approval agent
for the Commission and reviews initial filings and material
changes.
The following information is provided
to assist MCHIPs in complying with applicable statutes and regulations
regarding their complaint system filing. An MCHIP must file
its policies and procedures for initial approval. Subsequent
to that, only material changes to the approved filing (policies
and procedures) need to be filed. This office encourages MCHIPs
to contact the office if there is a question as to whether a
change is material. Generally, but not always, a material change
is one that adversely affects a covered person.
Documents needed for review:
- Complaint and Grievance Procedures distributed to MCHIP enrollees
who wish to register a written complaint, grievance or appeal.
- Sample adverse decision letter, acknowledgement of appeal
letter and appeal denial letters sent to MCHIP enrollees. These
letters should include contact information for the Office of
the Managed Care Ombudsman.
- The final adverse decision letter sent to the MCHIP enrollee.
- A statement from the MCHIP documenting that the MCHIP is aware
of and will comply with the requirements for the record keeping
of complaints and the submission of the annual complaint report
as described below. If internal policies are included that attest
to this, that is acceptable. We only need the pertinent portions
of the internal policies, we do not need internal policies in
their entirety.
Does the complaint system provide reasonable
procedures for the resolution of written complaints?
See Virginia Code §38.2-5804
The MCHIP must document that a complete
record of written complaints from the policyholder/subscriber
or claimant is maintained since the last examination and for
no less than 5 years. A complete record includes:
- the total number of complaints;
- their classification by line of insurance;
- the nature of each complaint;
- the disposition of these complaints; and
- the time it took to process each complaint.
See Virginia Code §§38.2-5804
A.1 and 38.2-511
Are complaint forms and/or written procedures provided to covered
persons who wish to register written complaints?
See Virginia Code §38.2-5804
A.2
Do the forms/procedures include the address
and phone number of the MCHIP licensee to which complaints shall
be directed?
See Virginia Code §38.2-5804
A.2
Do the forms/procedures include the correct mailing address,
telephone number and e-mail address of the Office of the Managed
Care Ombudsman?
See Virginia Code §38.2-5804
A.2
Do the forms/procedures specify any required
time limits/deadlines for filing grievances/appeals imposed
by or on behalf of the MCHIP?
See Virginia Code §38.2-5804
A.2
The forms/procedures must include a clear and understandable
description of the covered person’s right to appeal adverse
decisions pursuant to Virginia Code §32.1-137.15:
- Is the appellant notified of the results
of the appeal process no later than sixty working days after
the MCHIP receives the required documentation?
- Does the sample final adverse decision
letter state the criteria used and the clinical reason for the
decision?
- Does the sample final adverse decision
letter provide notification to the covered person or treating
healthcare provider of a clear and understandable written notification
of: (i) the right to appeal final adverse decisions to the Bureau
of Insurance in accordance with Chapter 59 of Title 38.2, (ii)
the procedures for making such an appeal, (iii) the binding
nature and effect of such an appeal, and (iv) a copy of the
then current Appeal of Final Adverse Decision Form or such other
form or forms as may then be required by the BOI pursuant to
14VAC5-215-120? Specifically the notification must advise the
covered person that, except in the instance of fraud, any such
appeal herein may preclude such person’s exercise of any
other right or remedy relating to such adverse decision.
- Does the sample final adverse decision
letter include the mailing address, telephone number, and e-mail
address of the Office of the Managed Care Ombudsman?
See Virginia Code §§38.2-5804
A.2 and 32.1-137.15,
and 14VAC5-215-20
Do the forms/procedures allow for the treating healthcare provider
to request an expedited appeal of the adverse decision or adverse
reconsideration by telephone? An expedited appeal is warranted
when the treating healthcare provider determines that the regular
appeals process would delay the rendering of health care in
a manner that would be detrimental to the health of the patient
or would subject the cancer patient to pain.
See Virginia Code §§38.2-5804
A.2 and 32.1-137.15
Do the forms/procedures require that the expedited appeal be
decided no later than one business day after receipt by the
UR entity of all necessary information? (No more than 24 hours
to consider a final adverse decision that relates to a prescription
to alleviate cancer pain.)
See Virginia Code §§38.2-5804
A.2, 32.1-137.13,
and 32.1-137.15
In the event that a request for an expedited appeal is denied
by the UR entity, procedures must be in place for the following:
- immediately notifying the appellant
of the decision by phone, fax, or e-mail;
- informing the appellant that they have
the right to file a request for an expedited appeal with the
BOI. This notification must be followed within 24 hours by a
written notice to the appellant and the treating healthcare
provider informing them of the right to appeal the decision
to the BOI and providing them with the forms for filing the
appeal.
See 14VAC5-215-50
In the event that an appeal that is reviewed
as expedited results in a final adverse decision from the UR
entity, procedures must be in place for the following:
- immediately notifying the person who
requested the expedited review of the final adverse decision;
- immediately notifying the appellant,
by telephone, fax, or e-mail, that the appellant is eligible
for an expedited appeal to the Bureau of Insurance;
- notifying the appellant and the treating
healthcare provider in writing within 24 hours, informing them
of the right to appeal to the BOI and providing the appropriate
forms to file.
See 14VAC5-215-50
Does the MCHIP address the requirement
to submit an annual complaint report to the State Health Commissioner
and Office of the Managed Care Ombudsman?
See Virginia Code §38.2-5804
C
The MCHIP must document that the following information will
be kept in a manner as to enable the MCHIP to submit to the
Office of the Managed Care Ombudsman and the State Health Commissioner,
an annual complaint report in a form prescribed by the Commission
and the Board of Health:
- the total number of complaints handled;
- the disposition of the complaints;
- a compilation of the nature and causes underlying the complaints
filed;
- the time it took to process and resolve each complaint;
- the number, amount, and disposition of malpractice claims
adjudicated during the year with respect to any of the MCHIP’s
affiliated providers.
See Virginia Code §38.2-5804
C
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