Health Plan Grievance and Appeal Processes

Bulletin 291 HEALTH PLAN GRIEVANCE AND APPEAL PROCESSES It is important for carriers to bear in mind that consumer access to thorough and fair appeal and grievance processes is critical to achieving consumer confidence in their health plans. Time Limits on Pursuing Appeal and Grievance Rights Bureau of Insurance Rule Chapter 850(9)(C)(1) gives Maine health plan consumers the right to submit a grievance to their health plan, "concerning any matter." Rule 850(5)(S) defines "grievance" as: a written complaint submitted by or on behalf of a covered person regarding the: (1) Availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review; (2) Claims payment, handling or reimbursement for health care services; or (3) Matters pertaining to the contractual relationship between a covered person and a health carrier. Rule 850 is silent with regard to whether carriers may impose contractual time limits on the filing of a grievance under a covered person’s health plan. The Bureau will not permit carriers to rigidly invoke contractual time limits on pursuing a grievance where the covered person’s delay in pursuing their grievance rights is reasonable under the circumstances and no prejudice to the carrier is attributable to the delay. Similarly, the Bureau expects carriers to accommodate reasonable and non-prejudicial delays in covered persons’ pursuit of their right to appeal an adverse utilization review determination. The Appeal and Grievance Process Rule 850 at Sections (8)(G)(1)(c)(ii) and (9)(C)(b)(ii) specifically require adverse appeal and grievance determination notices to include an explanation of the reviewers’ understanding of the covered person’s grievance or appeal. Carriers are reminded that appeal and grievance processes must specifically address all issues raised by the complaining covered person, and must address all documentation or other evidence submitted or presented by the covered person to the appeal or grievance panel. Failure to substantively address all issues raised by a covered person on appeal or grievance may result in penalties for violating the requirements of Rule 850. Date: April 13, 1999 _________________________________ Alessandro A. Iuppa Superintendent of Insurance NOTE: This bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties or privileges nor is it intended to provide legal advice. Readers are encouraged to consult applicable statutes and regulations and to contact the Bureau of Insurance if additional information is needed.