1. (a) Managed care organizations (MCO) shall develop and maintain a system and process for taking, tracing, reviewing, and reporting member complaints.
2. (b) MCOs shall establish and maintain internal procedures for the resolution of member complaints. The procedures must be in writing. The procedures must be detailed and specific regarding how complaints are to be taken, to whom complaints are referred, and by when a complaint must be resolved.
3. (c) MCOs shall establish a procedure to assist members in understanding and using the MCO's internal complaint process. The members' complaint procedure must be in writing and distributed to each member upon enrollment. The member must also receive written notice of the procedure each time the member's benefits are being reduced, denied, or terminated for any reason. The procedure must be easy for members to understand and simple to follow. The procedure must contain a prominent notice to the member that they retain all of their rights as Medicaid recipients to a fair hearing through the department, in addition to the MCO's complaint process.
4. (d) The department shall review the MCO's complaint procedures to determine they comply with the department's standards before approval for MCO use of the complaint procedure is given by the department. Reports containing complaint summaries shall be submitted to the department in compliance with department policy.
5. (e) The department shall retain the authority to make the final decision following the department's fair hearing process.

Source Note:The provisions of this §353.415 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561.