33-31-303. Complaint system. (1) (a) Each authorized health maintenance organization shall establish and maintain a complaint system to provide reasonable procedures to resolve written complaints initiated by enrollees. A health maintenance organization may not use a complaint system:
(i) before the commissioner approves it; and
(ii) unless the health maintenance organization describes it in each evidence of coverage issued or delivered to an enrollee in this state.
(b) Each time the health maintenance organization denies a claim or initiates disenrollment, cancellation, or nonrenewal, it shall notify the affected enrollee of the right to file a complaint and the procedure for filing a complaint.
(c) Each health maintenance organization shall acknowledge a complaint within 10 days of receiving it.
(d) Each health maintenance organization shall retain records of all complaints for 3 years and shall develop a summary for each year that must include:
(i) a description of the procedures of the complaint system;
(ii) the total number of complaints handled through the complaint system, a compilation of causes underlying the complaints filed, the date on which each complaint was filed, the date on which each complaint was resolved, the disposition of each complaint filed, the time it took to process each complaint, and a summary of each administrative change made because of a complaint; and
(iii) the number, amount, and disposition of malpractice claims made by enrollees of the health maintenance organization that were settled during the year by the health maintenance organization.
(e) The health maintenance organization shall annually on or before March 1 file with the commissioner the summary described in subsection (1)(d) for the preceding year.
(2) The commissioner shall hold in confidence the information provided by the health maintenance organization pursuant to subsection (1)(d)(iii).
(3) The commissioner may examine a complaint system.
History: En. Sec. 11, Ch. 457, L. 1987.
