Insurers must have grievance procedures for resolving enrollees' complaints and formal grievances. Such procedures must include a right to a grievance review by a panel, a right to a second review by a separate panel, and an opportunity to appear before at least one of the panels. A process must exist for expedited review in emergency situations. Insurers must also take steps to ensure that the points of access to primary care, specialty care and hospital services are identified for enrollees along with information on how to obtain the names, qualifications and titles of practitioners. Confidentiality of patient information must be protected.
All denials are subject to appeals.
A provider's request for prior authorization of nonemergency services must be answered within two business days and qualified health care personnel must be available for same day telephone responses to inquiries concerning certification of continued length of stays. When prior approval for a service of other covered item is required and obtained, unless there is a misrepresentation, the approval shall be final and may not be rescinded after the service ofr other covered item has been provided. Copyright 1996 by Physicians Who Care All Rights Reserved.