2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9398 - Standard reviews of grievances not involving an adverse determination

(a) Health insurance organizations or issuers shall establish written procedures for standard reviews of grievances that do not involve an adverse determination.
(b)
(1) The procedures shall permit a covered person or enrollee, or his/her authorized representative, to file a grievance that does not involve an adverse determination with the health insurance organization or issuer under this section.
(2)
(A) A covered person or enrollee, or his/her authorized representative, shall be entitled to submit written material for the persons designated by the health insurance organization or issuer to consider when conducting the standard review.
(B) The health insurance organization or issuer shall notify the covered person or enrollee or, if applicable, his/her authorized representative, of such covered person or enrollee's rights pursuant to paragraph (A) of this clause within three (3) business days after receiving the grievance.
(c)
(1) Upon receipt of the grievance, a health insurance organization or issuer shall designate one or more persons to conduct the standard review.
(2) To conduct the standard review of the grievance, the health insurance organization or issuer shall not designate the same person that handled the matter that is the subject of such grievance.
(3) The health insurance organization or issuer shall provide the covered person or enrollee or, if applicable, his/her authorized representative, with the name, address, and telephone number of the persons designated to conduct the standard review.
(d) The health insurance organization or issuer shall provide written notification of the decision to the covered person or enrollee or, if applicable, his/her authorized representative, within thirty (30) calendar days after the receipt of the grievance.
(e) The written decision issued pursuant to subsection (d) shall contain:
(1) The titles and qualifying credentials of the persons participating in the standard review process (the reviewers).
(2) A statement of the reviewers' understanding of the grievance.
(3) The reviewers' decision in clear terms and the contract basis or medical rationale for the covered person or enrollee to respond to the health insurance organization or issuer's position.
(4) A reference to the evidence or documentation used as the basis for the decision.
(5) If applicable, a written statement including:
(A) A description of the process to obtain an additional voluntary review if the covered person or enrollee wishes to request a voluntary review pursuant to § 9399 of this title, and
(B) the written procedures governing the voluntary review, including any required timeframe for the review.
(6) Notice of the covered person or enrollee’s right to contact the Office of the Insurance Commissioner and the Office of the Patient’s Advocate for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.080, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 28, eff. 30 days after July 10, 2013.