Minimum Time Allowed for a Consumer to File a Grievance

PURPOSE: This rule sets forth the minimum amount of time a health carrier that offers a managed care plan can require an enrollee or member to file an appeal. This rule is promulgated pursuant to section 376.1399, RSMo, and implements sections 376.1382 and 376.1385, RSMo. (1) Definitions. (A) “Adverse determination” shall have the same meaning as found in section 376.1350, RSMo. (B) “Grievance” shall have the same meaning as found in section 376.1350, RSMo. (C) “Health carrier” shall have the same meaning as found in section 376.1350, RSMo. (D) “Managed care component” shall mean a plan that offers an incentive to use specific providers or requires the use of utilization review. (E) “Utilization review” shall have the same meaning as found in section 376.1350, RSMo. (2) Minimum Time to File a Grievance. (A) No health carrier that offers a plan with a managed care component shall limit the time that a first level grievance may be filed to less than one hundred eighty (180) days from the date that written notice was sent from the health carrier to the enrollee informing the enrollee of the adverse determination. (B) In the case of a grievance filed for reasons other than an adverse determination, the health carrier shall not limit the time a first level grievance may be filed to less than one hundred eighty (180) days from the date the health carrier sent notice to the enrollee informing the enrollee of the event that gave rise to the grievance. (C) No health carrier that offers a plan with a managed care component shall limit the time that a second level grievance may be filed to less than one hundred eighty (180) days from the date the carrier allows to file the first level grievance or less than one hundred eighty (180) days from the date the health carrier sent notification to the person who submitted the grievance of the carrier’s resolution of said first level grievance, whichever is later. (D) Nothing in this section shall limit or supersede any statute of limitations found in the Revised Statutes of Missouri. AUTHORITY: sections 374.045 and 376.1399, RSMo 2000.* Original rule filed May 2, 2005, effective Dec. 30, 2005. *Original authority: 374.045, RSMo 1967, amended 1993, 1995 and 376.1399, RSMo 1997, amended 1997.