NY Pub Health L § 4408-A-2 (2021)
2021 New York Laws PBH - Public Health Article 44 - Health Maintenance Organizations 4408-A*2 - Grievance Procedure.

* §  4408-a. Grievance procedure. 1. A health maintenance organization licensed pursuant  to  article  forty-three  of  the  insurance  law  or certified pursuant to this article, and any other organization certified pursuant  to  this  article  shall  establish  and  maintain a grievance procedure. Pursuant to such procedure, enrollees shall  be  entitled  to seek   a  review  of  determinations  by  the  organization  other  than determinations subject to the provisions of article forty-nine  of  this chapter.   2.  (a)  An organization shall provide to all enrollees written notice of the grievance procedure in the member handbook and at any  time  that the  organization  denies  access  to  a  referral  or determines that a requested benefit is not covered pursuant to the terms of the  contract; provided,  however,  that  nothing  herein  shall be deemed to require a health care provider to provide  such  notice.  In  the  event  that  an organization  denies a service as an adverse determination as defined in article forty-nine of this chapter, the organization  shall  inform  the enrollee or the enrollee's designee of the appeal rights provided for in article forty-nine of this chapter.  (b)  The  notice to an enrollee describing the grievance process shall explain: (i) the process for filing a grievance with  the  organization; (ii) the timeframes within which a grievance determination must be made; (iii)  the  right of an enrollee to designate a representative to file a grievance on behalf of the  enrollee;  and  (iv)  notice  of  the  name, address,  phone number and website of the department designated consumer assistance program and the independent substance use disorder and mental health ombudsman established by section 33.27 of the mental hygiene  law within notices of adverse grievances and appeals determinations.  (c)  The  organization  shall  assure  that the grievance procedure is reasonably accessible to those who do not speak English.   3. (a) The organization may require an enrollee to file a grievance in writing, by letter or by a grievance form which shall be made  available by  the organization and which shall conform to applicable standards for readability.  (b)  Notwithstanding  the  provisions  of  paragraph   (a)   of   this subdivision,  an  enrollee  may  submit  an oral grievance in connection with: (i) a denial of, or failure to pay for,  a  referral;  or  (ii)  a determination  as  to whether a benefit is covered pursuant to the terms of the enrollee's contract. In connection with the submission of an oral grievance, an organization may require that the enrollee sign a  written acknowledgment of the grievance prepared by the organization summarizing the  nature  of  the  grievance.  Such  acknowledgment  shall  be mailed promptly to the enrollee, who shall sign and return the  acknowledgment, with  any  amendments, in order to initiate the grievance. The grievance acknowledgment shall prominently state that the enrollee must  sign  and return  the acknowledgment to initiate the grievance. If an organization does not require such a signed acknowledgment, an oral  grievance  shall be initiated at the time of the telephone call.  (c) Upon receipt of a grievance, the organization shall provide notice specifying  what  information  must  be  provided to the organization in order to render a decision on the grievance.  (d) (1) An organization shall designate personnel to accept the filing of an enrollee's grievance by toll-free telephone  no  less  than  forty hours  per week during normal business hours and, shall have a telephone system available to take calls during other than normal  business  hours and  shall  respond to all such calls no less than the next business day after the call was recorded.  (2)  Notwithstanding  the  provisions  of  subparagraph  one  of  this paragraph,  an organization may, in the alternative, designate personnel  to accept the filing of an enrollee's grievance by  toll-free  telephone not  less than forty hours per week during normal business hours and, in the case of grievances subject to subparagraph (i) of  subdivision  four of this section, on a twenty-four hour a day, seven day a week basis.   4.  Within  fifteen  business  days  of  receipt of the grievance, the organization shall provide  written  acknowledgment  of  the  grievance, including  the  name,  address and telephone number of the individual or department designated by the organization to respond to  the  grievance. All  grievances  shall  be resolved in an expeditious manner, and in any event, no more than: (i) forty-eight hours  after  the  receipt  of  all necessary information when a delay would significantly increase the risk to  an  enrollee's  health;  (ii)  thirty  days after the receipt of all necessary  information  in  the  case  of  requests  for  referrals   or determinations   concerning  whether  a  requested  benefit  is  covered pursuant to the contract; and (iii) forty-five days after the receipt of all necessary information in all other instances.   5. The organization shall designate one or more qualified personnel to review the grievance; provided further, that when the grievance pertains to clinical matters, the personnel shall include, but not be limited to, one or more licensed, certified or registered health care professionals.   6. The notice of a determination of the grievance  shall  be  made  in writing  to the enrollee or to the enrollee's designee. In the case of a determination made in conformance with subparagraph (i)  of  subdivision four  of this section, notice shall be made by telephone directly to the enrollee with written notice to follow within three business days.   7. The notice of a  determination  shall  include:  (i)  the  detailed reasons for the determination; (ii) in cases where the determination has a  clinical  basis,  the clinical rationale for the determination; (iii) the procedures for  the  filing  of  an  appeal  of  the  determination, including  a  form  for the filing of such an appeal; and (iv) notice of the name, address, phone number and website of the department designated consumer assistance program and the independent substance  use  disorder and  mental  health ombudsman established by section 33.27 of the mental hygiene  law  within  notices  of   adverse   grievances   and   appeals determinations.   8.  An  enrollee  or  an  enrollee's designee shall have not less than sixty  business  days  after  receipt  of  notice   of   the   grievance determination to file a written appeal, which may be submitted by letter or by a form supplied by the organization.   9.  Within  fifteen  business  days  of  receipt  of  the  appeal, the organization  shall  provide  written  acknowledgment  of  the   appeal, including  the  name,  address  and  telephone  number of the individual designated by the  organization  to  respond  to  the  appeal  and  what additional  information,  if  any,  must  be  provided  in order for the organization to render a decision.   10. The determination of an appeal on a clinical matter must  be  made by  personnel  qualified  to  review  the  appeal,  including  licensed, certified or registered health care professionals who did not  make  the initial  determination,  at  least  one  of whom must be a clinical peer reviewer  as  defined  in  article  forty-nine  of  this  chapter.   The determination  of  an  appeal on a matter which is not clinical shall be made by qualified personnel at a higher level  than  the  personnel  who made the grievance determination.   11.  The  organization  shall  seek to resolve all appeals in the most expeditious manner and shall make a determination and provide notice  no more than:  (i)  two  business days after the receipt of all necessary information when a delay would significantly increase  the  risk  to  an  enrollee's health; and  (ii)   thirty  business  days  after  the  receipt  of  all  necessary information in all other instances.   12. The notice of a determination on an appeal shall include: (i)  the detailed  reasons  for  the  determination;  and (ii) in cases where the determination has a clinical  basis,  the  clinical  rationale  for  the determination.   13.  An  organization  shall  not retaliate or take any discriminatory action against an enrollee because an enrollee has filed a grievance  or appeal.   14.  An  organization  shall  maintain  a  file  on each grievance and associated appeal, if any, that shall include the date the grievance was filed; a copy of the grievance, if any; the date of  receipt  of  and  a copy  of  the  enrollee's  acknowledgment  of the grievance, if any; the determination made  by  the  organization  including  the  date  of  the determination   and   the   titles  and,  in  the  case  of  a  clinical determination, the  credentials  of  the  organization's  personnel  who reviewed the grievance. If an enrollee files an appeal of the grievance, the file shall include the date and a copy of the enrollee's appeal, the determination  made  by  the  organization  including  the  date  of the determination  and  the  titles   and,   in   the   case   of   clinical determinations,  the  credentials,  of  the organization's personnel who reviewed the appeal.   15. An organization shall have procedures for obtaining an enrollee's, or enrollee's designee's, preference for receiving notifications,  which shall  be  in  accordance  with applicable federal law and with guidance developed by the commissioner. Written and telephone notification to  an enrollee  or  the enrollee's designee under this section may be provided by electronic means where the enrollee or the  enrollee's  designee  has informed  the  organization  in  advance of a preference to receive such notification by electronic  means.  An  organization  shall  permit  the enrollee  and  the  enrollee's  designee to change the preference at any time.  The  organization  shall  retain   documentation   of   preferred notification  methods  and present such records to the commissioner upon request.   16. The rights and remedies conferred in this article  upon  enrollees shall  be  cumulative  and  in  addition to and not in lieu of any other rights or remedies available under law.   * NB There are 2 § 4408-a's