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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 408. Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees
12/30/2024

12VAC5-408-130. Complaint system, complaint examination and investigation.

A. Each MCHIP licensee shall establish and maintain for each of its MCHIPs a complaint system approved by the department and the Bureau of Insurance to provide reasonable procedures for the resolution of complaints.

B. The department, on behalf of the commissioner and in cooperation with the Bureau of Insurance, shall examine the complaint system for compliance of the system with applicable statutes and regulations and shall require corrections or modifications as necessary. The effectiveness of the complaint system in allowing covered persons, or their duly authorized representatives, to have issues regarding quality assurance appropriately resolved shall be assessed by the department.

C. The department has the responsibility to investigate complaints regarding quality of care violations filed by or on behalf of covered persons.

D. Every person from whom information is sought in an investigation of a complaint against an MCHIP licensee shall cooperate in producing, or allowing reasonable access during regular business hours to, the books, records, files, accounts, papers, documents, and any or all computer or other recordings of the licensee being examined or those of any person or delegated services entity delivering health care services under contract, affiliation, delegation or other arrangement. Information shall be limited to that which is relevant to the investigation in question.

E. Deficiencies found during a complaint investigation shall be corrected as required in 12VAC5-408-110.

F. When the investigation is complete, the MCHIP licensee and the complainant will be notified of the findings of the investigation.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 16, Issue 7, eff. January 20, 2000; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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