9395

(a) Health insurance organizations or issuers shall maintain written records to document all grievances received during a calendar year (the register).\n(b) A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with § 9397 of this title. A request for a standard review of a grievance not involving an adverse determination shall be processed in compliance with § 9398 of this title.\n(c) A request for an additional voluntary review of a grievance shall be processed in compliance with § 9399 of this title.\n(d) For each grievance, the register shall contain at least the following information:\n(1) A general description of the reason(s) for the grievance;\n(2) the date received;\n(3) the date of each review or, if applicable, review meeting;\n(4) decision/resolution at each level of the grievance, if applicable;\n(5) date of decision/resolution at each level, if applicable, and\n(6) name of the covered person or enrollee for whom the grievance was filed.\n(e) The register shall be maintained in a manner that is clear and accessible to the Commissioner.\n(f)\n(1) Health insurance organizations or issuers shall retain the

whom the grievance was filed.\n(e) The register shall be maintained in a manner that is clear and accessible to the Commissioner.\n(f)\n(1) Health insurance organizations or issuers shall retain the register compiled for a calendar year for the longer of five (5) years or until the Commissioner has issued a final report of an examination that contains a review of the register for that calendar year.\n(2)\n(A) Health insurance organizations or issuers shall submit to the Commissioner, at least annually, a report in the format specified by him/her.\n(B) The report shall include the following for each type of health plan offered by the health insurance organization or issuer:\n(i) The certificate of compliance required by § 9396(c) of this title;\n(ii) the number of covered persons or enrollees;\n(iii) the total number of grievances;\n(iv) the number of grievances for which a covered person or enrollee requested an additional voluntary grievance review pursuant to § 9399 of this title;\n(v) the number of grievances resolved at each level, if applicable, and their decision/resolution;\n(vi) the number of grievances appealed to the Commissioner of which the health insurance

is title;\n(v) the number of grievances resolved at each level, if applicable, and their decision/resolution;\n(vi) the number of grievances appealed to the Commissioner of which the health insurance organization or issuer has been informed;\n(vii) the number of grievances referred to alternative dispute resolution procedures, such as mediation or arbitration, or resulting in litigation, and\n(viii) a synopsis of actions taken to correct the problems identified.\nHistory —Aug. 29, 2011, No. 194, § 22.050, eff. 180 days after Aug. 29, 2011.