Montana Code 33-32-306. Grievance reporting and recordkeeping requirements — definition
33-32-306. Grievance reporting and recordkeeping requirements — definition. (1) (a) A health insurance issuer shall maintain within a register all written records that document grievances received during a calendar year, including the notices and claims associated with the grievances.
Terms Used In Montana Code 33-32-306
- Covered person: means a policyholder, a certificate holder, a member, a subscriber, an enrollee, or another individual participating in a health plan. See Montana Code 33-32-102
- Grievance: means a written complaint or an oral complaint if the complaint involves an urgent care request submitted by or on behalf of a covered person regarding:
(a)availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
(b)claims payment, handling, or reimbursement for health care services; or
(c)matters pertaining to the contractual relationship between a covered person and a health insurance issuer. See Montana Code 33-32-102
- Health insurance issuer: has the meaning provided in 33-22-140. See Montana Code 33-32-102
- Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
- Oversight: Committee review of the activities of a Federal agency or program.
(b)For the purposes of this section, “register” means the written record of grievances received by a health insurance issuer that includes the notices and claims associated with the grievances as required by this section.
(2)Retention of the records in the register must be as provided in subsection (6), except that a health insurance issuer shall maintain for at least 6 years those records specified by the commissioner by rule.
(3)A health insurance issuer shall:
(a)maintain the records in a manner that is reasonably clear and accessible to the commissioner; and
(b)make the records available for examination, on request, by covered persons, the commissioner, and any appropriate federal oversight agency.
(4)A request for a review of a grievance involving an adverse determination must be processed in compliance with 33-32-308 and must be included in the register.
(5)For each grievance, the register must contain, at a minimum, the following information:
(a)a general description of the reason for the grievance;
(b)the date received;
(c)the date of each review or, if applicable, review meeting;
(d)a report on the resolution of the grievance, if applicable;
(e)the date of the resolution, if applicable; and
(f)the name of the covered person for whom the grievance was filed.
(6)Subject to the provisions of subsection (2), a health insurance issuer shall retain the register compiled in a calendar year for 3 years or until the commissioner has adopted a final report of an examination that contains a review of the register for that calendar year, whichever is longer.
(7)(a) At least annually, a health insurance issuer shall submit to the commissioner a report in the format specified by the commissioner.
(b)The report must include for each type of health plan offered by the health insurance issuer:
(i)the certificate of compliance required by 33-32-307(4)(b);
(ii)the number of covered persons;
(iii)the total number of grievances;
(iv)the number of grievances resolved, if applicable, and their resolution;
(v)the number of grievances referred to an alternative dispute resolution procedure or resulting in litigation; and
(vi)a synopsis of actions taken or being taken to correct problems that have been identified.