§ 154.17. Complaints.
(a) Under the complaint process established by sections 2141—2143 of the act (40 P. S. § § 991.2141—991.2143), the Department will consider complaints including those regarding issues of contract exclusions, noncovered benefit disputes and potential violation of insurance statutes, including the Unfair Insurance Practices Act (40 P. S. § § 1171.1—1171.15). The enrollee may be represented by an attorney or other individual before the Department. The Department of Health will focus on complaint issues including those involving enrollee quality of care and quality of service. The grievance process, which is administered by the Department of Health, includes review of the medical necessity and appropriateness of services otherwise covered by the managed care plan. Examples of the types of complaints which may be filed with the Department include:
(1) Denial of payment by the plan based upon contractual limitation rather than on medical necessity—for example, denial of payment for a visit by an enrollee on the basis that the enrollee failed to meet the contractual requirement of obtaining a referral from a primary care provider. However, a primary care provider’s refusal to make an enrollee referral to a specialist, on the basis that the referral is not medically necessary, would be considered a grievance.
(2) Disputes involving a noncovered benefit or contract exclusion—for example, a request for additional physical therapy services, even if medically necessary, beyond the number specified in the enrollee contract.
(3) Problems relating to one or more of the following:
(i) Coordination of benefits.
(ii) Subrogation.
(iii) Conversion coverage.
(iv) Alleged nonpayment of premium.
(v) Dependent coverage.
(vi) Involuntary disenrollment.
(b) Managed care plans shall establish an internal complaint process with two levels of review to allow enrollees to file oral and written complaints regarding a participating health care provider or the coverage, operations or management policies of the plan.
(c) Inquiries, complaints and questions regarding premium rate increases may be filed with the Department without the necessity of following the plan’s internal complaint process.
(d) If plans establish time frames for the filing of complaints and grievances with the plan, they shall allow the enrollees at least 45 days to file a complaint or grievance from the date of the occurrence of the issue being complained about or the date of the enrollees’ receipt of notice of the plan’s decision.
(e) Managed care plans shall complete the initial level of review of an enrollee complaint within 30 days of receipt of the complaint. The plan shall notify the enrollee in writing of the plan’s decision following the initial review within 5 business days of the decision. The notification shall include the basis for the decision and the procedure to file a request for a second level review of the decision of the initial review committee.
(f) Managed care plans shall complete the second level of review of an enrollee complaint within 45 days of receipt of the enrollee’s request for review. The enrollee has the right to appear before the second level review committee. The plan shall notify the enrollee in writing within 5 business days of the rendering of a decision by the second level complaint review committee, including the basis for the decision and the procedure for appealing the decision to the Department.
(g) To expedite the complaint review process, enrollees should follow and complete the plan’s internal complaint process before filing an appeal of the complaint decision with the Department or the Department of Health. Under section 2143 of the act (40 P. S. § 991.2143), the Department may communicate with the appropriate parties to assist in the resolution of the complaint.
(h) Appeals of complaints shall be submitted to the Department within 15 days of receipt of notice of the second level review committee’s decision.
(i) Appeals of complaints to the Department shall include the following information:
(1) The enrollee’s name, address and daytime phone number.
(2) The enrollee’s policy number, identification number and group number (if applicable).
(3) A copy of the complaint submitted to the managed care plan.
(4) The reasons for appealing the managed care plan’s decision.
(5) Correspondence and decisions from the managed care plan regarding the complaint.
(6) Whether the enrollee will be represented by an attorney or other individual before the Department.
(j) The Department will notify the plan if a complaint appeal has been filed. The plan shall provide copies of all records from the initial and second level review to the Department. This information shall be provided to the Department within 30 days of the Department’s notice to the plan of the complaint appeal.
(k) When an appeal is transferred from the Department to the Department of Health, the original submission date of the appeal will be utilized to determine compliance with the filing time frame in accordance with section 2142(a) of the act (40 P. S. § 991.2142(a)), which relates to the appeal of a complaint. The Department will notify the enrollee and the managed care plan in writing and promptly transmit the appeal to the Department of Health for consideration.
(l) The Department will provide the managed care plan and the enrollee with a copy of the final determination of an appealed complaint.
(m) Complaint appeals under subsection (i) may be filed with the Department at the following address:
Pennsylvania Insurance Department Bureau of Consumer Services 1321 Strawberry Square Harrisburg, Pennsylvania 17120
Cross References This section cited in 28 Pa. Code § 9.703 (relating to internal complaint process).
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