Montana Code 33-31-303. Complaint system
33-31-303. Complaint system. (1) (a) Each authorized health maintenance organization shall establish and maintain a complaint system to provide reasonable procedures to resolve written complaints initiated by enrollees. A health maintenance organization may not use a complaint system:
Terms Used In Montana Code 33-31-303
- Commissioner: means the commissioner of insurance of the state of Montana. See Montana Code 33-31-102
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Enrollee: means a person:
(a)who enrolls in or contracts with a health maintenance organization;
(b)on whose behalf a contract is made with a health maintenance organization to receive health care services; or
(c)on whose behalf the health maintenance organization contracts to receive health care services. See Montana Code 33-31-102
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health maintenance organization: means a person who provides or arranges for basic health care services to enrollees on a prepaid basis, either directly through provider employees or through contractual or other arrangements with a provider or a group of providers. See Montana Code 33-31-102
- Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
(i)before the commissioner approves it; and
(ii)unless the health maintenance organization describes it in each evidence of coverage issued or delivered to an enrollee in this state.
(b)Each time the health maintenance organization denies a claim or initiates disenrollment, cancellation, or nonrenewal, it shall notify the affected enrollee of the right to file a complaint and the procedure for filing a complaint.
(c)Each health maintenance organization shall acknowledge a complaint within 10 days of receiving it.
(d)Each health maintenance organization shall retain records of all complaints for 3 years and shall develop a summary for each year that must include:
(i)a description of the procedures of the complaint system;
(ii)the total number of complaints handled through the complaint system, a compilation of causes underlying the complaints filed, the date on which each complaint was filed, the date on which each complaint was resolved, the disposition of each complaint filed, the time it took to process each complaint, and a summary of each administrative change made because of a complaint; and
(iii)the number, amount, and disposition of malpractice claims made by enrollees of the health maintenance organization that were settled during the year by the health maintenance organization.
(e)The health maintenance organization shall annually on or before March 1 file with the commissioner the summary described in subsection (1)(d) for the preceding year.
(2)The commissioner shall hold in confidence the information provided by the health maintenance organization pursuant to subsection (1)(d)(iii).
(3)The commissioner may examine a complaint system.