Health Plan Complaint and Appeal Rules

(a) A health carrier with enrollees in this State shall establish and maintain a procedure to provide for the resolution of an enrollee's complaints and internal appeals. The procedure shall provide for expedited internal appeals under section 432E-6.5. The definition of medical necessity in section 432E-1.4 shall apply in a health carrier's complaints and internal appeals procedures. (b) The health carrier shall at all times make available its complaints and internal appeals procedures. The complaints and internal appeals procedures shall be reasonably understandable to the average layperson and shall be provided in a language other than English upon request. (c) A health carrier shall decide any expedited internal appeal as soon as possible after receipt of the complaint, taking into account the medical exigencies of the case, but not later than seventy-two hours after receipt of the request for expedited appeal. (d) A health carrier shall send notice of its final internal determination within sixty days of the submission of the complaint to the enrollee, the enrollee's appointed representative, if applicable, the enrollee's treating provider, and the commissioner. The notice shall include the following information regarding the enrollee's rights and procedures: (1) The enrollee's right to request an external review; (2) The one hundred thirty day deadline for requesting an external review; (3) Instructions on how to request an external review; and (4) Where to submit the request for an external review. In addition to these general requirements, the notice shall conform to the requirements of sections 432E-35 and 432E-36.