Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-203 - PREPAID LIMITED HEALTH SERVICE ORGANIZATIONS AND DISCOUNT MEDICAL PLAN ORGANIZATIONS › Section 69O-203.075 - Subscriber Grievance Procedure

Current through Reg. 50, No. 138; July 16, 2024
Every PLHSO shall have a subscriber grievance procedure,
				  which is outlined in all master group and individual contracts as well as any
				  certificate or member handbook provided to subscribers. Standards for the
				  subscriber grievance procedure are as follows:
(1) Both informal and formal steps shall be
				available to resolve the grievance. A grievance is not considered formal until
				a written complaint has been received by the PLHSO;
(2) Each PLHSO shall designate a grievance
				coordinator who will be responsible for the implementation of the PLHSOs
				grievance procedure;
(3) A phone
				number shall be specified for the subscriber to call to present a grievance and
				a phone number shall be provided to enable the subscriber to contact the
				grievance coordinator. For entities with 25 or more employees, each phone
				number must be toll free or within the subscriber's geographic area and provide
				reasonable access to the PLHSO without undue delays. There shall be an adequate
				number of phone lines to handle incoming grievances;
(4) An address shall be included for written
				grievances;
(5) Each level of the
				grievance procedure shall have some person with problem solving authority to
				participate in each step of the grievance procedure;
(6) The PLHSO shall process the written
				subscriber grievance in a reasonable length of time not to exceed 60 days. If
				the complaint involves the collection of information outside the service area,
				the PLHSO will have 30 additional days to process the subscriber complaint
				through all phases of the grievance procedure. A grievance which is arbitrated
				pursuant to chapter 682, F.S., is permitted an additional time limitation not
				to exceed 270 days from the date the PLHSO is first notified of the grievance.
				Each PLHSO shall notify the Office of all arbitrated grievances;
(7) The subscriber grievance procedure shall
				state that the subscriber always has the right to file a complaint with or seek
				assistance from the Office;
(8)
				There shall be medical professional involvement in reviewing medically related
				grievances. Medical professional involvement shall not be limited to the
				subscriber's primary care professional, but shall include another
				professional;
(9) If a meeting with
				the subscriber is necessary, the location of the meeting shall be at the
				administrative office of the PLHSO within the service area or at a location
				within the service area which is convenient to the subscriber;
(10) The PLHSO may not establish time limits
				of less than one year from the date of occurrence for the subscriber to file a
				grievance;
(11) Each PLHSO shall
				maintain an accurate record of each formal grievance. Each record shall include
				the following:
(a) A complete description of
				the grievance, the subscriber's name and address, the provider's name and
				address, and the PLHSO's name and address;
(b) A complete description of the PLHSO's
				findings due to the grievance procedure;
(c) A complete description of the PLHSO's
				conclusion pertaining to the grievance as well as the PLHSO's final disposition
				of the grievance; and,
(d) A
				statement as to which level of the grievance procedure the complaint has been
				processed and how many more levels of the grievance procedure are remaining
				before the complaint has been processed through the PLHSO's entire grievance
				procedure.