Texas Insurance Code 843.253 – Complaint Investigation and Resolution
(a) A health maintenance organization shall investigate each complaint received in accordance with the health maintenance organization’s policies and in compliance with this chapter.
(b) After a health maintenance organization has investigated a complaint, the health maintenance organization shall issue a response letter to the complainant within the time prescribed by § 843.252(c) that:
(1) explains the health maintenance organization’s resolution of the complaint;
(2) states the specific medical and contractual reasons for the resolution;
(3) states the specialization of any physician or other provider consulted; and
(4) contains a complete description of the process for appeal, including the deadlines for the appeals process and the deadlines for the final decision on the appeal.
Terms Used In Texas Insurance Code 843.253
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.