1. (a) Health maintenance organizations (HMO) must develop and maintain a system and process for taking, tracking, reviewing, and reporting member complaints.
2. (b) HMOs must 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) HMO's must establish a procedure to assist members in understanding and using the HMOs 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 he or she retains all rights as Medicaid Clients to a fair hearing through the Commission, in addition to the HMOs complaint process. The HMO notice to the Member should comply with the Fair Hearing rules found at Chapter 357 of this title, relating to Fair Hearings.
4. (d) The Commission will review the HMOs complaint procedures to determine if they comply with HHSC's standards before HHSC approves use of the procedures. Reports containing complaint summaries must be submitted to the Commission in compliance with Commission's policy.
5. (e) The Commission shall retain the authority to make the final decision following the Commission'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; amended to be effective August 10, 2005, 30 TexReg 4466.