(a) Not later than seven calendar days after receipt
of an oral or written complaint, the HCC must:
(1) acknowledge receipt of the complaint in writing;
(2) acknowledge the date of receipt; and
(3) provide a description of the HCC's complaint procedures,
its appeal process for complaints filed by patients, and deadlines
associated with each.
(b) An HCC must investigate each complaint received
in accord with the HCC's policies and in compliance with Insurance
Code §848.107 and this subchapter.
(c) After an HCC has investigated a complaint, the
HCC must issue a resolution letter to the complainant not later than
the 30th calendar day after the HCC receives the written complaint
or the close of any hearing held under §13.493(2) of this title
(relating to Rights of Physicians) that:
(1) explains the HCC'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, if the complainant is a patient who is
dissatisfied with the resolution of the complaint, that the complainant
may file an appeal of the complaint resolution, or may file a complaint
with the department.
(d) In situations in which a patient complaint has
been appealed, the HCC must issue a decision letter after considering
the appeal that includes specific reasons for the decision and states
that if the complainant is dissatisfied with the resolution of the
complaint, the appeal, or the complaint process, the complainant may
file a complaint with the department.
(e) An HCC must maintain a complaint log that captures
each complaint by category, including at least the following:
(1) quality of care or services;
(2) accessibility and availability of services, providers,
or both;
(3) complaint procedures;
(4) physician and provider contracts;
(5) claims processing and bill payment disputes; and
(6) miscellaneous.
(f) Each HCC must maintain the complaint log required
under subsection (e) 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.
|