TITLE 41

INSURANCE

CHAPTER 39

MANAGED CARE REFORM

41-3918.  Grievance system. (1) Every managed care organization shall establish a grievance system to resolve grievances initiated by members concerning health care services. The system shall provide reasonable procedures for the resolution of grievances, and shall include an appeals process which affords the member the right to a prompt review by a grievance panel before whom the member has the right either to appear or be heard, or both. A managed care organization offering a managed care plan for which a certificate of authority is required shall have its grievance system approved by the director and shall submit to the director an annual report in a form prescribed by the director which shall include:

(a)  A description of the procedures of the grievance system; and

(b)  The total number of grievances handled through the grievance system and a compilation of causes underlying the grievances filed.

(2)  Every managed care organization shall maintain records of grievances filed with it concerning health care services and each managed care organization for which a certificate of authority is required shall submit to the director a summary report at such times and in such form as the director may require. Grievances involving other persons shall be referred to such persons with a copy to the director.

(3)  The director may examine a grievance system of a managed care organization for which a certificate of authority is required, subject to the limitations concerning health records of individuals set forth in section 41-3909(3), Idaho Code.

(4)  Every managed care organization must show evidence that such grievance procedures have been reviewed and approved by the member representatives through their participation on advisory panels or other reasonable mechanisms as set forth in section 41-3916, Idaho Code.

History:

[41-3918, added 1974, ch. 177, sec. 18, p. 1444; am. 1997, ch. 204, sec. 20, p. 593; am. 2008, ch. 203, sec. 4, p. 654.]