(a) Not later than seven calendar days after receipt
of an oral or written complaint, a 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 must investigate each oral or written
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 must issue a resolution letter to the complainant not later
than the 30th calendar day after the network receives the written
complaint that:
(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;
(4) explains the network's procedures and deadlines
for filing an appeal of the complaint; and
(5) 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 title (relating to Submitting Complaints to
the Department).
(d) A network must maintain a complaint-and-appeal
log regarding each complaint and categorize each complaint and appeal
as one or more of the following:
(1) quality of care or services;
(2) accessibility and availability of services or providers;
(3) utilization review;
(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-and-appeal
log required under subsection (d) of this section and documentation
on each complaint, appeal, complaint proceeding, and action taken
on the complaint until the third anniversary after the date the complaint
was received.
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