Section 4802. Grievance procedure

(a) An insurer which offers a managed
  care product shall establish and maintain  a  grievance  procedure  with
  regard  to  such  managed  care  product.  Pursuant  to  such procedure,
  insureds shall be entitled to seek a review  of  determinations  by  the
  insurer   with   regard   to  such  managed  care  product,  other  than
  determinations subject to the provisions of article forty-nine  of  this
  chapter.
    (b) (1) An insurer shall provide to all insureds written notice of the
  grievance  procedure  in  the  contract and at any time that the insurer
  denies access to a referral or determines that a  requested  benefit  is
  not  covered  pursuant  to the terms of the contract; provided, however,
  that nothing herein shall be deemed to require a health care provider to
  provide such notice. In the event that an insurer denies a service as an
  adverse determination as defined in article forty-nine of this  chapter,
  the  insurer  shall  inform the insured or the insured's designee of the
  appeal rights provided for in article forty-nine of this chapter.
    (2) The notice to an insured describing the  grievance  process  shall
  explain:
    (i) the process for filing a grievance with the insurer;
    (ii)  the  timeframes  within  which a grievance determination must be
  made; and
    (iii) the right of an insured to designate a representative to file  a
  grievance on behalf of the insured.
    (3)   The  insurer  shall  assure  that  the  grievance  procedure  is
  reasonably accessible to those who do not speak English.
    (c) (1) The insurer may require an insured  to  file  a  grievance  in
  writing,  by letter or by a grievance form which shall be made available
  by the insurer, and which shall  conform  to  applicable  standards  for
  readability.
    (2)   Notwithstanding   the   provisions  of  paragraph  (1)  of  this
  subsection, an insured may submit an oral grievance in  connection  with
  (i)  a  denial  of,  or  failure  to  pay  for,  a  referral;  or (ii) a
  determination as to whether a benefit is covered pursuant to  the  terms
  of  the insured's contract. In connection with the submission of an oral
  grievance, an insurer may  require  that  the  insured  sign  a  written
  acknowledgment of the grievance, prepared by the insurer summarizing the
  nature of the grievance. Such acknowledgment shall be mailed promptly to
  the  insured,  who  shall  sign  and return the acknowledgment, with any
  amendments,  in  order  to  initiate  the   grievance.   The   grievance
  acknowledgment  shall  prominently  state that the insured must sign and
  return the acknowledgment to initiate the grievance. If an insurer  does
  not  require  such  a  signed acknowledgment, an oral grievance shall be
  initiated at the time of the telephone call.
    (3) Upon receipt of a grievance,  the  insurer  shall  provide  notice
  specifying  what information must be provided to the insurer in order to
  render a decision on the grievance.
    (4) (i) An insurer shall designate personnel to accept the  filing  of
  an  insured's  grievance by toll-free telephone no less than forty hours
  per week during normal business hours and, shall have a telephone system
  available to take calls during other  than  normal  business  hours  and
  shall  respond to all such calls no less than one business day after the
  call was recorded.
    (ii) Notwithstanding  the  provisions  of  subparagraph  (i)  of  this
  paragraph,  an  insurer  may, in the alternative, designate personnel to
  accept the filing of an insured's grievance by  toll-free  telephone  no
  less  than forty hours per week during normal business hours and, in the
  case of grievances subject to subparagraph (1) of subsection (d) of this
  section, on a twenty-four hour a day, seven day a week basis.

    (d) Within fifteen business days of  receipt  of  the  grievance,  the
  insurer shall provide written acknowledgment of the grievance, including
  the  name,  address and telephone number of the individual or department
  designated by the insurer to respond to the  grievance.  All  grievances
  shall  be  resolved  in an expeditious manner, and in any event, no more
  than:
    (1) forty-eight hours after the receipt of all  necessary  information
  when  a  delay  would  significantly  increase  the risk to an insured's
  health;
    (2) thirty days after the receipt of all necessary information in  the
  case  of  requests  for referrals or determinations concerning whether a
  requested benefit is covered pursuant to the contract; and
    (3) forty-five days after the receipt of all necessary information  in
  all other instances.
    (e)  The  insurer  shall  designate one or more qualified personnel to
  review the grievance; provided further, that when the grievance pertains
  to clinical matters, the personnel shall include, but not be limited to,
  one or more licensed, certified or registered health care professionals.
    (f) The notice of a determination of the grievance shall  be  made  in
  writing  to  the  insured or to the insured's designee. In the case of a
  determination made in conformance with subparagraph  (1)  of  subsection
  (d)  of  this section, notice shall be made by telephone directly to the
  insured with written notice to follow within three business days.
    (g) The notice of a determination shall include:
    (1) the detailed reasons for the determination;
    (2) in cases  where  the  determination  has  a  clinical  basis,  the
  clinical rationale for the determination; and
    (3)  the  procedures for the filing of an appeal of the determination,
  including a form for the filing of such an appeal.
    (h) An insured or an insured's designee shall have not less than sixty
  business days after receipt of notice of the grievance determination  to
  file  a  written  appeal,  which may be submitted by letter or by a form
  supplied by the insurer.
    (i) Within fifteen business days of receipt of the appeal, the insurer
  shall provide written acknowledgment of the appeal, including the  name,
  address and telephone number of the individual designated by the insurer
  to  respond  to the appeal and what additional information, if any, must
  be provided in order for the insurer to render a decision.
    (j) The determination of an appeal on a clinical matter must  be  made
  by  personnel  qualified  to  review  the  appeal,  including  licensed,
  certified or registered health care professionals who did not  make  the
  initial  determination,  at  least  one  of whom must be a clinical peer
  reviewer  as  defined  in  article  forty-nine  of  this  chapter.   The
  determination  of  an  appeal on a matter which is not clinical shall be
  made by qualified personnel at a higher level  than  the  personnel  who
  made the grievance determination.
    (k)  The  insurer  shall  seek  to  resolve  all  appeals  in the most
  expeditious manner and shall make a determination and provide notice  no
  more than:
    (1)  two  business days after the receipt of all necessary information
  when a delay would significantly  increase  the  risk  to  an  insured's
  health; and
    (2)   thirty   business  days  after  the  receipt  of  all  necessary
  information in all other instances.
    (l)  The notice of a determination on an appeal shall include:
    (1) the detailed reasons for the determination; and
    (2) in cases  where  the  determination  has  a  clinical  basis,  the
  clinical rationale for the determination.

    (m)  An  insurer shall not retaliate or take any discriminatory action
  against an insured because an insured has filed a grievance or appeal.
    (n)  An insurer shall maintain a file on each grievance and associated
  appeal, if any, that shall include the date the grievance was  filed;  a
  copy  of the grievance, if any; the date of receipt of and a copy of the
  insured's acknowledgment of the grievance,  if  any;  the  determination
  made  by  the  insurer  including the date of the determination, and the
  titles and, in the case of a clinical determination, the credentials  of
  the  insurer's personnel who reviewed the grievance. If an insured files
  an appeal of the grievance, the file shall include the date and  a  copy
  of the insured's appeal, the determination made by the insurer including
  the  date  of  the  determination  and  the  titles  and, in the case of
  clinical determinations, the credentials of the insurer's personnel  who
  reviewed the appeal.
    (o)  The  rights  and remedies conferred in this article upon insureds
  shall be cumulative and in addition to and not  in  lieu  of  any  other
  rights or remedies available under law.