Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.078 - Subscriber Grievance Procedure

Current through Reg. 50, No. 138; July 16, 2024
Every HMO shall have a subscriber grievance procedure. A
				  detailed description of the HMO's subscriber grievance procedure shall be
				  included in all group and individual contracts as well as in any certificate or
				  member handbook provided to subscribers. This procedure shall be administered
				  at no cost to the subscriber. An HMO subscriber grievance procedure must
				  include the following:
(1) Both
				informal and formal steps shall be available to resolve the grievance. A
				grievance is not considered formal until a written complaint is executed by the
				subscriber or completed on such forms as prescribed and received by the
				HMO;
(2) Each HMO shall designate
				at least one grievance coordinator who will be responsible for the
				implementation of the HMO's grievance procedure;
(3) Phone numbers shall be specified by the
				HMO for the subscriber to call to present an informal grievance or to contact
				the grievance coordinator. Each phone number shall be toll free within the
				subscriber's geographic area and provide reasonable access to the HMO without
				undue delays. There must 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 HMO shall process the formal written
				subscriber grievance in a reasonable length of time not to exceed 60 days,
				unless the subscriber and HMO mutually agree to extend the time frame set forth
				by this rule. If the complaint involves the collection of information outside
				the service area, the HMO will have 30 additional days to process the
				subscriber complaint through all phases of the grievance procedure. The time
				limitations prescribed in this paragraph requiring completion of the grievance
				process within 60 days shall be tolled after the HMO has notified the
				subscriber, in writing, that additional information is required in order to
				properly complete review of the complaint. Upon receipt by the HMO of the
				additional information requested, the time for completion of the grievance
				process set forth herein shall resume. A grievance which is arbitrated pursuant
				to Chapter 682, F.S., is permitted an additional time limitation not to exceed
				210 days from the date the HMO receives a written request for arbitration from
				the subscriber;
(7) The HMO shall
				have physician involvement in reviewing medically related grievances. Physician
				involvement in the grievance process should not be limited to the subscriber's
				primary care physician, but may include at least one other physician;
(8) The HMO shall offer to meet with the
				subscriber during the formal grievance process. The location of the meeting
				shall be at the administrative offices of the HMO within the service area or at
				a location within the service area which is convenient to the
				subscriber;
(9) The HMO may not
				establish time limits of less than one year from the date of occurrence for the
				subscriber to file a formal grievance;
(10) Each HMO 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
				HMO's name and address,
(b) A
				complete description of the HMO's factual findings and conclusions after
				completion of the full formal grievance procedure,
(c) A complete description of the HMO's
				conclusions pertaining to the grievance as well as the HMO's final disposition
				of the grievance; and,
(d) A
				statement as to which levels 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 HMO's entire grievance
				procedure;