| (a) Managed care organizations (MCOs) must develop
and maintain a system and process for taking, tracking, reviewing,
and reporting member complaints and appeals.
(b) MCOs must establish and maintain internal procedures
for the resolution of member complaints and appeals. The procedures
must be in writing. The procedures must be detailed and specific regarding
how complaints and appeals are to be taken, to whom complaints are
referred, and by when a complaint must be resolved.
(c) MCOs must establish a procedure to assist members
in understanding and using the MCO's internal complaint and appeal
process. The member's complaint and appeal procedure must be:
(1) in writing and distributed to each member upon
enrollment;
(2) provided to the member each time the member's benefits
are reduced, denied, or terminated for any reason;
(3) easy for members to understand and follow; and
(4) contain a prominent notice to the member that complies
with the fair hearing rules found in Chapter 357, Subchapter A of
this title (relating to Uniform Fair Hearing Rules), stating the member
retains all rights as a Medicaid client to a fair hearing through
the Health and Human Services Commission (HHSC), in addition to the
MCO's complaint and appeal process.
(d) HHSC will review the MCO's complaint and appeals
procedures to determine if they comply with HHSC's standards before
HHSC approves use of the procedures. Reports containing complaint
summaries must be submitted to HHSC in compliance with HHSC policy.
(e) HHSC retains the authority to make the final decision
following HHSC's fair hearing process.
|
| Source Note: The provisions of this §353.415 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283 |
