2023 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