Notice Requirements of an Adverse Determination

PURPOSE: This rule sets forth with greater specificity the requirements of written notification when a health carrier informs an enrollee of a health plan that includes a managed care component of an adverse determination. This rule is promulgated pursuant to section 376.1399, RSMo, and implements section 376.1363.5, RSMo. (1) A written notification of an adverse determination shall be printed in clear legible type of at least twelve (12)-point font. (2) The notice shall explain the principal reason for the adverse determination in language easily understood by a person with an eighth grade reading level. A health carrier may determine the reading level of a notice without including medical terminology which describes an enrollee’s medical condition, proper names, telephone numbers and addresses. (3) The notice shall explain how an enrollee initiates a grievance review. If an enrollee is eligible for an expedited review pursuant to section 376.1389, RSMo, then the notice shall explain how an enrollee initiates an expedited review. (4) The notice shall explain how an enrollee as defined in section 376.1350(14), RSMo initiates a grievance review of the adverse determination with the director. The notice shall explain that an enrollee may file a grievance with the director at any time. The notice shall also list the Consumer Affairs Division’s toll-free telephone number. (5) The notice shall describe how the enrollee can request a written statement of the clinical rationale and clinical review criteria used to make the adverse determination. (6) If the Health Care Financing Administration’s Medicare or Medicaid plans have notification requirements for grievance procedures, those notification requirements shall satisfy the requirements of this rule for notification of enrollees in those plans if the notices comply with all Missouri statutory requirements. (7) The notice shall inform enrollees that they have a right to have a relative, friend, lawyer, the department or other representative help them with a grievance. AUTHORITY: sections 374.045 and 376.1363.5, RSMo 2000 and section 376.1399, RSMo Supp. 2007.* Original rule filed Nov. 3, 1997, effective June 30, 1998. Amended: Filed Nov. 1, 2007, effective July 30, 2008. *Original authority: 374.045, RSMo 1967, amended 1993, 1995; 376.1363, RSMo 1997; and 376.1399, RSMo 1997, amended 1997, 2007.