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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 10WORKERS' COMPENSATION HEALTH CARE NETWORKS
SUBCHAPTER GCOMPLAINTS
RULE §10.121Complaints; Deadlines for Response and Resolution

(a) Not later than seven calendar days after receipt of an oral or written complaint, the network must:

  (1) acknowledge receipt of the complaint in writing;

  (2) acknowledge the date of receipt; and

  (3) provide a description of the network's complaint procedures and deadlines.

(b) A network shall investigate each complaint received in accordance with the network's policies and in compliance with this subchapter.

(c) After a network has investigated a complaint, the network shall issue a resolution letter to the complainant not later than the 30th calendar day after the network receives the written complaint which:

  (1) explains the network's resolution of the complaint;

  (2) states the specific reasons for the resolution;

  (3) states the specialization of any health care provider consulted; and

  (4) states that, if the complainant is dissatisfied with the resolution of the complaint or the complaint process, the complainant may file a complaint with the department as described in §10.122 of this subchapter (relating to Submitting Complaints to the Department).

(d) A network shall maintain a complaint log regarding each complaint and categorize each complaint as one or more of the following:

  (1) quality of care or services;

  (2) accessibility and availability of services or providers;

  (3) utilization review and retrospective review, as applicable;

  (4) complaint procedures;

  (5) health care provider contracts;

  (6) bill payment, as applicable;

  (7) fee disputes; and

  (8) miscellaneous.

(e) Each network must maintain the complaint log required under subsection (d) of this section and documentation on each complaint, complaint proceeding, and action taken on the complaint until the third anniversary after the date the complaint was received.


Source Note: The provisions of this §10.121 adopted to be effective December 5, 2005, 30 TexReg 8099

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