| (a) CHIP member complaints and appeals are subject
to disposition consistent with applicable federal and state laws,
regulations and rules, including the Texas Insurance Code and Texas
Department of Insurance (TDI) regulations.
(b) Any member, or a representative acting on behalf
of the member, may file a complaint or appeal with their managed care
organization (MCO) through the MCO's internal appeal and complaint
system.
(c) Any person, including those dissatisfied with the
MCO's resolution of a member complaint or appeal, may submit a complaint
to report an alleged violation to TDI.
(d) Any member or a representative acting on behalf
of the member may request an external review of the MCO's adverse
benefit determination, to be conducted by an independent review organization,
when:
(1) the MCO internal appeal and complaint system regarding
the adverse benefit determination has been exhausted; and
(2) the member or representative acting on behalf of
the member is dissatisfied with the MCO's resolution of the appeal
of an adverse benefit determination.
|
