68 Questions and Answers 1. The Act provides for a new consumer complaint system, a new consumer and provider grievance system, and requires the certification of utilization review organizations. Act 68 also provides for a wide range of other consumer and provider protections such as consumer disclosure, continuity of care, prompt payment of claims, etc. 2. Complaints can be filed orally or in writing with the managed care plan by a member or a provider, with the written consent of the member. After undergoing a two-step review at the plan, decisions on complaints can be appealed to either the Department of Health or the Insurance Department, depending on the nature of the complaint.
Grievances also undergo a two-step review at the managed care plan.
Then, decisions on grievances can be appealed to the managed care plan. The plan will notify the Department of Health which will, in turn, assign the case to a certified, independent utilization review organization for review and decision. The Act becomes effective January 1, 1999. Even though the law itself is effective on January 1, your rights under Act 68 do not become effective until your next health insurance coverage renewal date on or after January 1. For many enrollees, the effective date of their coverage will be January 1.