(16) 
PHYSICIAN
CREDENTIALING
STAND-
ARDS.—Standards used by the organization in the
credentialing of participating physicians.
(17) FORMULARIES.—Information on prescrip-
tion drug formularies used by the organization, con-
sistent with section 4(i).
(18) LOSS-RATIO.—Its loss-ratio.
(d) INFORMATION SUPPLIED UPON REQUEST.—For
purposes of subsection (a)(2), the information described
in this subsection concerning a managed care organization
offering a managed care plan is as follows:
(1) ANNUAL
FINANCIAL
STATEMENT.—The
most recent annual financial statement of the orga-
nization.
(2) SUBSCRIBER
CONTRACT.—A copy of the
most recent individual, direct pay subscriber con-
tract, or, in the case of a group health plan, any
contract between the plan and a health insurance is-
suer providing coverage under the plan.
(3) CONSUMER COMPLAINTS.—Information re-
lating to consumer complaints compiled pursuant to
insurance or other law.
(4) CHARGES AND BENEFITS FOR SERVICES.—
Information on the enrollee charges for all covered
items and services, including, for the point of service
option described in section 5(e), the amounts that
are payable with respect to items and services fur-
nished by nonparticipating health care professionals
and providers.
(5) 
CONFIDENTIALITY
OF
MEDICAL
RECORDS.—Information on the procedures used by
the organization to protect the confidentiality of
medical records maintained in relation to enrollees.
(6) QUALITY
ASSURANCE
PROGRAMS.—A de-
scription of quality assurance programs maintained
by the organization in relation to the plan.
(7) COVERAGE OF EXPERIMENTAL OR INVES-
TIGATIONAL
DRUGS.—A description of procedures
used by the organization to determine whether
drugs, devices, or treatments in clinical trials are ex-
perimental or investigational.
(8) PROVIDER AFFILIATIONS.—Information on
affiliations of participating health care professionals
with participating hospitals.
(9) CLINICAL REVIEW CRITERIA.—Upon written
request, a description of the specific clinical written
review criteria relating to a particular condition or
disease and how such criteria are used.
(10) PARTICIPATION PROCEDURES AND QUALI-
FICATIONS.—A description of the written application
procedures and qualification requirements for pro-
viders to be considered for participation under the
plan.
(11) OFFICIALS.—A list of the names, business
addresses, and official positions of the membership
of the board of directors, officers, or persons with an
ownership or control interest in the organization.
(e) NOTICE OF TERMINATION OF PROVIDERS.—A
managed care organization shall provide written notice to
each enrollee within 15 business days of the date that the
organization is aware that the participation of a health
care provider, that is currently in a course of treating the
enrollee, is being withdrawn or terminated. The organiza-
tion shall include in such notice the procedures under sec-
tion 5(f) for the enrollee to continue to receive care from
the provider.
SEC. 9. GRIEVANCE PROCEDURES AND DEADLINE FOR RE-
SPONDING TO REQUESTS FOR COVERAGE OF
SERVICES.
(a) GRIEVANCE PROCEDURES.—A managed care or-
ganization shall provide meaningful procedures for hear-
ing and resolving grievances between the organization (or
any entity or individual through which the organization
provides health care services) and its enrollees.
(b) DETAILS.—The procedures provided under sub-
section (a) shall include—
(1) recorded (written or otherwise) procedures
for registering and responding to complaints and
grievances in a timely manner;
(2) documentation concerning the substance of
complaints, grievances, and actions taken concerning
such complaints and grievances, which shall be in
writing;
(3) procedures to ensure a resolution of a com-
plaint or grievance;
(4) the compilation and analysis of complaint
and grievance data;
(5) procedures to expedite the complaint proc-
ess if the complaint involves a dispute about the cov-
erage of an immediately and urgently needed service;
and
(6) procedures to ensure that if an enrollee
orally notifies the organization about a complaint,
the organization (if requested) must send the en-
rollee a complaint form that includes the telephone
numbers and addresses of member services, and a
description of the organization’s grievance proce-
dure.
The Secretary may establish deadlines for the complaint
procedures under paragraph (5) in order to ensure timely
resolution of disputes involving immediately and urgently
needed services.
(c) APPEALS PROCESS.—Each managed care organi-
zation shall adopt an appeals process to enable enrollees
to appeal decisions that are adverse to them. Such a proc-
ess shall include—
(1) the right to a review by a grievance panel
composed of clinical peer professionals who are in
the same or similar specialty or field that would pro-
vide the item or service involved in the grievance;
(2) the right to a second review with a different
panel that is independent of the organization and
that is composed of clinical peer professionals who
are in the same or similar specialty or field that
would provide the item or service involved in the
grievance, or to a review through an impartial arbi-
tration process which shall be described in writing
by the organization;
(3) a process for completion of review in the
case of urgent or emergency care services within 24
hours; and
(4) covering the costs of all appeals and not im-
posing any such costs on an enrollee.