2023 New York Laws › ISC - Insurance › Article 48 - Managed Care Health Insurance Contracts › 4802 - Grievance Procedure.

§  4802.  Grievance  procedure.  (a) An insurer which offers a managed
care product shall establish and maintain  a  grievance  procedure  with
regard  to  such  managed  care  product.  Pursuant  to  such procedure,
insureds shall be entitled to seek a review  of  determinations  by  the
insurer   with   regard   to  such  managed  care  product,  other  than
determinations subject to the provisions of article forty-nine  of  this
chapter.
(b) (1) An insurer shall provide to all insureds written notice of the
grievance  procedure  in  the  contract and at any time that the insurer
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 insurer denies a service as an
adverse determination as defined in article forty-nine of this  chapter,
the  insurer  shall  inform the insured or the insured's designee of the
appeal rights provided for in article forty-nine of this chapter.
(2) The notice to an insured describing the  grievance  process  shall
explain:
(i) the process for filing a grievance with the insurer;
(ii)  the  timeframes  within  which a grievance determination must be
made; and
(iii) the right of an insured to designate a representative to file  a
grievance on behalf of the insured.
(3)   The  insurer  shall  assure  that  the  grievance  procedure  is
reasonably accessible to those who do not speak English.
(c) (1) The insurer may require an insured  to  file  a  grievance  in
writing,  by letter or by a grievance form which shall be made available
by the insurer, and which shall  conform  to  applicable  standards  for
readability.
(2)   Notwithstanding   the   provisions  of  paragraph  (1)  of  this
subsection, an insured 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 insured's contract. In connection with the submission of an oral
grievance, an insurer may  require  that  the  insured  sign  a  written
acknowledgment of the grievance, prepared by the insurer summarizing the
nature of the grievance. Such acknowledgment shall be mailed promptly to
the  insured,  who  shall  sign  and return the acknowledgment, with any
amendments,  in  order  to  initiate  the   grievance.   The   grievance
acknowledgment  shall  prominently  state that the insured must sign and
return the acknowledgment to initiate the grievance. If an insurer  does
not  require  such  a  signed acknowledgment, an oral grievance shall be
initiated at the time of the telephone call.
(3) Upon receipt of a grievance,  the  insurer  shall  provide  notice
specifying  what information must be provided to the insurer in order to
render a decision on the grievance.
(4) (i) An insurer shall designate personnel to accept the  filing  of
an  insured'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 one business day after the
call was recorded.
(ii) Notwithstanding  the  provisions  of  subparagraph  (i)  of  this
paragraph,  an  insurer  may, in the alternative, designate personnel to
accept the filing of an insured's grievance by  toll-free  telephone  no
less  than forty hours per week during normal business hours and, in the
case of grievances subject to subparagraph (1) of subsection (d) of this
section, on a twenty-four hour a day, seven day a week basis.
(d) Within fifteen business days of  receipt  of  the  grievance,  the
insurer shall provide written acknowledgment of the grievance, including
the  name,  address and telephone number of the individual or department
designated by the insurer to respond to the  grievance.  All  grievances
shall  be  resolved  in an expeditious manner, and in any event, no more
than:
(1) forty-eight hours after the receipt of all  necessary  information
when  a  delay  would  significantly  increase  the risk to an insured's
health;
(2) 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
(3) forty-five days after the receipt of all necessary information  in
all other instances.
(e)  The  insurer  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.
(f) The notice of a determination of the grievance shall  be  made  in
writing  to  the  insured or to the insured's designee. In the case of a
determination made in conformance with subparagraph  (1)  of  subsection
(d)  of  this section, notice shall be made by telephone directly to the
insured with written notice to follow within three business days.
(g) The notice of a determination shall include:
(1) the detailed reasons for the determination;
(2) in cases  where  the  determination  has  a  clinical  basis,  the
clinical rationale for the determination; and
(3)  the  procedures for the filing of an appeal of the determination,
including a form for the filing of such an appeal.
(h) An insured or an insured'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 insurer.
(i) Within fifteen business days of receipt of the appeal, the insurer
shall provide written acknowledgment of the appeal, including the  name,
address and telephone number of the individual designated by the insurer
to  respond  to the appeal and what additional information, if any, must
be provided in order for the insurer to render a decision.
(j) 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.
(k)  The  insurer  shall  seek  to  resolve  all  appeals  in the most
expeditious manner and shall make a determination and provide notice  no
more than:
(1)  two  business days after the receipt of all necessary information
when a delay would significantly  increase  the  risk  to  an  insured's
health; and
(2)   thirty   business  days  after  the  receipt  of  all  necessary
information in all other instances.
(l) The notice of a determination on an appeal shall include:
(1) the detailed reasons for the determination; and
(2) in cases  where  the  determination  has  a  clinical  basis,  the
clinical rationale for the determination.
(m)  An  insurer shall not retaliate or take any discriminatory action
against an insured because an insured has filed a grievance or appeal.
(n)  An insurer 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
insured's acknowledgment of the grievance,  if  any;  the  determination
made  by  the  insurer  including the date of the determination, and the
titles and, in the case of a clinical determination, the credentials  of
the  insurer's personnel who reviewed the grievance. If an insured files
an appeal of the grievance, the file shall include the date and  a  copy
of the insured's appeal, the determination made by the insurer including
the  date  of  the  determination  and  the  titles  and, in the case of
clinical determinations, the credentials of the insurer's personnel  who
reviewed the appeal.
(o)  An  insurer  shall have procedures for obtaining an insured's, or
insured's designee's,  preference  for  receiving  notifications,  which
shall  be  in  accordance  with applicable federal law and with guidance
developed by the superintendent. Written and telephone  notification  to
an  insured or the insured's designee under this section may be provided
by electronic means where the insured  or  the  insured's  designee  has
informed  the  insurer  in  advance  of  a  preference  to  receive such
notifications by electronic means. An insurer shall permit  the  insured
and  the  insured's  designee  to change the preference at any time. The
insurer shall retain documentation of preferred notification methods and
present such records to the superintendent upon request.
(p) The rights and remedies conferred in this  article  upon  insureds
shall  be  cumulative  and  in  addition to and not in lieu of any other
rights or remedies available under law.