Right to an Internal Grievance Process

(1) A carrier or utilization review organization shall maintain an internal grievance process that provides for adequate consideration and timely resolution of grievances. (2) There shall be only one level of review for an internal grievance, regardless of whether the carrier contracts with a utilization review organization or other entity that as part of its contractual responsibilities provides utilization review services or otherwise reviews internal grievances and issues determinations regarding these grievances. (3) A carrier may waive the internal grievance process, and allow the insured to seek immediate external review of an adverse determination, at the carrier's discretion and upon receiving a written request from the insured or the insured's authorized representative which clearly seeks a waiver of the internal grievance process and includes a request to proceed directly to external review. Any such request by the insured or insured's authorized representative must be provided to the carrier in writing within 48 hours of the insured's or insured's authorized representative's receipt of the notice of adverse determination. If the carrier waives the internal grievance process, the carrier shall notify the insured and the insured's authorized representative in writing within 48 hours of receiving the written request, and the insured or insured's authorized representative shall provide a copy of this written waiver to the Office of Patient Protection along with the timely request for external review. (4) The carrier or utilization review organization shall establish a clear process to allow the insured to request the appointment of an authorized representative to act on the insured’s behalf.