§ 4802. Grievance procedure. (a) An insurer which offers a managed\ncare product shall establish and maintain a grievance procedure with\nregard to such managed care product. Pursuant to such procedure,\ninsureds shall be entitled to seek a review of determinations by the\ninsurer with regard to such managed care product, other than\ndeterminations subject to the provisions of article forty-nine of this\nchapter.\n (b) (1) An insurer shall provide to all insureds written notice of the\ngrievance procedure in the contract and at any time that the insurer\ndenies access to a referral or determines that a requested benefit is\nnot covered pursuant to the terms of the contract; provided, however,\nthat nothing herein shall be deemed to require a health care provider to\nprovide such notice. In the event that an insurer denies a service as an\nadverse determination as defined in article forty-nine of this chapter,\nthe insurer shall inform the insured or the insured's designee of the\nappeal rights provided for in article forty-nine of this chapter.\n (2) The notice to an insured describing the grievance process shall\nexplain:\n (i) the process for filing a grievance with the insurer;\n (ii) the timeframes within which a grievance determination must be\nmade; and\n (iii) the right of an insured to designate a representative to file a\ngrievance on behalf of the insured.\n (3) The insurer shall assure that the grievance procedure is\nreasonably accessible to those who do not speak English.\n (c) (1) The insurer may require an insured to file a grievance in\nwriting, by letter or by a grievance form which shall be made available\nby the insurer, and which shall conform to applicable standards for\nreadability.\n (2) Notwithstanding the provisions of paragraph (1) of this\nsubsection, an insured may submit an oral grievance in connection with\n(i) a denial of, or failure to pay for, a referral; or (ii) a\ndetermination as to whether a benefit is covered pursuant to the terms\nof the insured's contract. In connection with the submission of an oral\ngrievance, an insurer may require that the insured sign a written\nacknowledgment of the grievance, prepared by the insurer summarizing the\nnature of the grievance. Such acknowledgment shall be mailed promptly to\nthe insured, who shall sign and return the acknowledgment, with any\namendments, in order to initiate the grievance. The grievance\nacknowledgment shall prominently state that the insured must sign and\nreturn the acknowledgment to initiate the grievance. If an insurer does\nnot require such a signed acknowledgment, an oral grievance shall be\ninitiated at the time of the telephone call.\n (3) Upon receipt of a grievance, the insurer shall provide notice\nspecifying what information must be provided to the insurer in order to\nrender a decision on the grievance.\n (4) (i) An insurer shall designate personnel to accept the filing of\nan insured's grievance by toll-free telephone no less than forty hours\nper week during normal business hours and, shall have a telephone system\navailable to take calls during other than normal business hours and\nshall respond to all such calls no less than one business day after the\ncall was recorded.\n (ii) Notwithstanding the provisions of subparagraph (i) of this\nparagraph, an insurer may, in the alternative, designate personnel to\naccept the filing of an insured's grievance by toll-free telephone no\nless than forty hours per week during normal business hours and, in the\ncase of grievances subject to subparagraph (1) of subsection (d) of this\nsection, on a twenty-four hour a day, seven day a week basis.\n (d) Within fifteen business days of receipt of the grievance, the\ninsurer shall provide written acknowledgment of the grievance, including\nthe name, address and telephone number of the individual or department\ndesignated by the insurer to respond to the grievance. All grievances\nshall be resolved in an expeditious manner,
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