* § 4408-a. Grievance procedure. 1. A health maintenance organization\nlicensed pursuant to article forty-three of the insurance law or\ncertified pursuant to this article, and any other organization certified\npursuant to this article shall establish and maintain a grievance\nprocedure. Pursuant to such procedure, enrollees shall be entitled to\nseek a review of determinations by the organization other than\ndeterminations subject to the provisions of article forty-nine of this\nchapter.\n 2. (a) An organization shall provide to all enrollees written notice\nof the grievance procedure in the member handbook and at any time that\nthe organization denies access to a referral or determines that a\nrequested benefit is not covered pursuant to the terms of the contract;\nprovided, however, that nothing herein shall be deemed to require a\nhealth care provider to provide such notice. In the event that an\norganization denies a service as an adverse determination as defined in\narticle forty-nine of this chapter, the organization shall inform the\nenrollee or the enrollee's designee of the appeal rights provided for in\narticle forty-nine of this chapter.\n (b) The notice to an enrollee describing the grievance process shall\nexplain: (i) the process for filing a grievance with the organization;\n(ii) the timeframes within which a grievance determination must be made;\n(iii) the right of an enrollee to designate a representative to file a\ngrievance on behalf of the enrollee; and (iv) notice of the name,\naddress, phone number and website of the department designated consumer\nassistance program and the independent substance use disorder and mental\nhealth ombudsman established by section 33.27 of the mental hygiene law\nwithin notices of adverse grievances and appeals determinations.\n (c) The organization shall assure that the grievance procedure is\nreasonably accessible to those who do not speak English.\n 3. (a) The organization may require an enrollee to file a grievance in\nwriting, by letter or by a grievance form which shall be made available\nby the organization and which shall conform to applicable standards for\nreadability.\n (b) Notwithstanding the provisions of paragraph (a) of this\nsubdivision, an enrollee may submit an oral grievance in connection\nwith: (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 enrollee's contract. In connection with the submission of an oral\ngrievance, an organization may require that the enrollee sign a written\nacknowledgment of the grievance prepared by the organization summarizing\nthe nature of the grievance. Such acknowledgment shall be mailed\npromptly to the enrollee, who shall sign and return the acknowledgment,\nwith any amendments, in order to initiate the grievance. The grievance\nacknowledgment shall prominently state that the enrollee must sign and\nreturn the acknowledgment to initiate the grievance. If an organization\ndoes not require such a signed acknowledgment, an oral grievance shall\nbe initiated at the time of the telephone call.\n (c) Upon receipt of a grievance, the organization shall provide notice\nspecifying what information must be provided to the organization in\norder to render a decision on the grievance.\n (d) (1) An organization shall designate personnel to accept the filing\nof an enrollee's grievance by toll-free telephone no less than forty\nhours per week during normal business hours and, shall have a telephone\nsystem available to take calls during other than normal business hours\nand shall respond to all such calls no less than the next business day\nafter the call was recorded.\n (2) Notwithstanding the provisions of subparagraph one of this\nparagraph, an organization may, in the alternative, designate personnel\nto accept the filing of an enrollee's grievance by toll-free telephone\nnot less than forty hours per week during normal business hours
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