Administrative Code

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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

12VAC5-408-180. Complaint system.

A. Every MCHIP licensee shall establish and maintain a system for the resolution of complaints brought by covered persons, or by providers acting on behalf of an covered person and with the covered person's consent, including complaints regarding availability, delivery, or quality of health care services, or any other matter pertaining to the covered person's contractual relationship or status as a third party beneficiary with the MCHIP.

The system shall include:

1. Written notification to all covered persons of the procedures, including telephone numbers and addresses, for contacting the MCHIP with a complaint and telephone numbers and addresses of the complaint unit of the center and the Office of the Managed Care Ombudsman to help with complaints or appeals;

2. A description of the process used to investigate and resolve complaints, including specific time lines for each step in the complaint process; and

3. A description of the process used to document and track the status of all complaints and compile the complaint information required to be reported to the department under § 32.1-137.6 C of the Code of Virginia.

B. Time lines for responding to complaints shall accommodate clinical urgency and shall not exceed 30 days from receipt of the complaint. Resolution of complaints shall not exceed 60 days from date of receipt of the complaint.

C. The MCHIP licensee shall keep records of complaints filed including:

1. Complaint identifier, using a unique identification code assigned consistently to the covered person;

2. Date complaint received;

3. A general description of the reason for the complaint;

4. Date of each review and hearing, if any;

5. The number of days to gather the information necessary to resolve the complaint;

6. Date closed;

7. Resolution of the complaint;

8. Record of internal actions necessary as a result of the complaint resolution, as applicable; and

9. Notification to the covered person of the resolution.

D. No covered person who exercises the right to file a complaint or an appeal shall be subject to disenrollment or otherwise penalized due to the filing of a complaint or appeal.

E. Complaint records shall be maintained from the date of the MCHIP licensee's last examination and for no less than five years.

F. A description of the systems for filing complaints and appeals shall be provided to covered persons at the time of enrollment and upon request thereafter.

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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