Section 376.1385

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS

Chapter 376

Effective - 28 Aug 1997, 2 histories, see footnote   (history) 

  376.1385.  Second-level review procedures. — 1.  Upon receipt of a request for second-level review, a health carrier shall submit the grievance to a grievance advisory panel consisting of:

  (1)  Other enrollees;

  (2)  Representatives of the health carrier that were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance; and

  (3)  Where the grievance involves an adverse determination, a majority of persons that are appropriate clinical peers in the same or similar specialty as would typically manage the case being reviewed that were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance.

  2.  Review by the grievance advisory panel shall follow the same time frames as a first level review, except as provided for in section 376.1389 if applicable.  Any decision of the grievance advisory panel shall include notice of the enrollee's or the health carrier's or plan sponsor's rights to file an appeal with the director's office of the grievance advisory panel's decision.  The notice shall contain the toll-free telephone number and address of the director's office.

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(L. 1997 H.B. 335)