PURPOSE: This rule sets forth the guidelines and procedures to be used by a health maintenance organization to resolve enrollee grievances. This rule is promulgated pursuant to section 354.485, RSMo and implements sections 354.430.3(2)(e) and 354.445, RSMo.

1. (1) Definitions.

   1. (A) Grievance means a complaint submitted in writing in accordance with the health maintenance organization’s (HMO) formal grievance procedure by or on behalf of the enrollee regarding the interpretation of the certificate of coverage or dissatisfaction with the quality of health care provided by an HMO employee or a contracted provider.
   2. (B) Grievance advisory panel means a panel established by the HMO which may review the HMO’s decision regarding grievances which have not been resolved to the satisfaction of the enrollee and which an enrollee has requested the panel to review. This panel must be comprised, at least in part, of enrollees and also may include representatives from the HMO, but shall not include anyone involved in the circumstances giving rise to the grievance, or in any subsequent investigation or determination of the grievance placed before it.

2. (2) An HMO shall set forth in its certificate of coverage the procedures for resolving enrollee grievances. At a minimum, the certificate of coverage shall include the following provisions:

   1. (A) The definition of a grievance;
   2. (B) How, where and to whom the enrollee should file his/her grievance; and

   3. (C) That upon receiving notification of a grievance related to payment of a bill for medical services, the HMO will—

      1. 1. Acknowledge receipt of the grievance

in writing within ten (10) working days unless it is resolved within that period of time;

1. 2. Conduct a complete investigation of

the grievance within twenty (20) working days after receipt of a grievance, unless the investigation cannot be completed within this time. If the investigation cannot be completed within twenty (20) working days after receipt of a grievance, the enrollee shall be notified in writing within thirty (30) working days time, and every thirty (30) working days after that, until the investigation is completed. The notice shall set forth the reasons for which additional time is needed for the investigation; 20 CSR 400-7

1. 3. Have within five (5) working days

after the investigation is completed, someone not involved in the circumstances giving rise to the grievance or its investigation decide upon the appropriate resolution of the grievance and notify the enrollee in writing of the HMO’s decision regarding the grievance and of any right to appeal. The notice shall explain the resolution of the grievance and any right to appeal. The notice shall explain the resolution of the grievance in terms which are clear and specific; and

1. 4. Notify, if the HMO has established a

grievance advisory panel, the enrollee of his/ her right to request the grievance advisory panel to review the HMO’s decision. This notice shall indicate that the grievance advisory panel is not obligated to conduct the review. This provision shall also state how, where and when the enrollee should make his/her request for this review.

1. (3) An HMO shall keep a record or report of the total number, type, nature and result of all grievances. Upon request by the director of the Department of Insurance or his/her appointee, the HMO shall provide, promptly, all those records or reports.
2. (4) An HMO, upon receipt of any inquiry from the Department of Insurance regarding a grievance, within fifteen (15) working days of receipt of the inquiry, shall furnish the department with a written response to the information requested.
3. (5) All written grievances shall be date stamped when received by the HMO. The date shall be legible and easily identified.
4. (6) The director of the Department of Insurance may institute disciplinary action for a violation of this rule in accordance with the provisions of section 354.550, RSMo and any other applicable law.

AUTHORITY: sections 354.430, 354.445 and 354.485, RSMo 1986.* Original rule filed April 14, 1992, effective Feb. 26, 1993.

*Original authority: 354.430, RSMo 1983; 354.445, RSMo 1983; and 354.485, RSMo 1983.