Office of the Insurance Commissioner Rules

(4) Each carrier shall reimburse reasonable costs of medical record duplication for reviews.

(5) Each carrier shall have written procedures to assure that reviews and second opinions are conducted in a timely manner.

1. Review determinations must be made within two business days of receipt of the necessary information on a proposed admission or service requiring a review determination.
2. The frequency of reviews for the extension of initial determinations must be based upon the severity or complexity of the patient's condition or on necessary treatment and discharge planning activity.
3. Retrospective review determinations must be completed within thirty days of receipt of the necessary information.
4. Notification of the determination shall be provided to the attending physician or ordering provider or facility and to the covered person within two days of the determination and shall be provided within one day of concurrent review determination. Notification shall include the number of extended days, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services.

1. Provide a clear explanation of the grievance process upon request, upon enrollment to new covered persons, and annually to covered person and subcontractors of the carrier.
2. Ensure that the grievance process is accessible to enrollees who are limited-English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to file a grievance.
3. Process as a grievance a covered person's expression of dissatisfaction about customer service or the quality or availability of a health service.
4. Implement procedures for registering and responding to oral andwritten grievances in a timely and thorough manner including the notification of a covered person that a grievance or appeal has been received.
5. Assist the covered person with all grievance and appeal processes.
6. Cooperate with any representative authorized in writing by the covered person.
7. Consider all information submitted by the covered person or representative.
8. Investigate and resolve all grievances and appeals.
9. Provide information on the covered person's right to obtain second opinions.
10. Track each appeal until final resolution; maintain, and make accessible to the commissioner for a period of three years, a log of all appeals; and identify and evaluate trends in appeals.