SECTION 353.415. Member Complaint and Appeal Procedures

(a) Managed care organizations (MCOs) must develop and maintain a system and process for taking, tracking, reviewing, and reporting member complaints and appeals.

(b) MCOs must establish and maintain internal procedures for the resolution of member complaints and appeals. The procedures must be in writing. The procedures must be detailed and specific regarding how complaints and appeals are to be taken, to whom complaints are referred, and by when a complaint must be resolved.

(c) MCOs must establish a procedure to assist members in understanding and using the MCO's internal complaint and appeal process. The member's complaint and appeal procedure must be:

(1) in writing and distributed to each member upon enrollment;

(2) provided to the member each time the member's benefits are reduced, denied, or terminated for any reason;

(3) easy for members to understand and follow; and

(4) contain a prominent notice to the member that complies with the fair hearing rules found in Chapter 357, Subchapter A of this title (relating to Uniform Fair Hearing Rules), stating the member retains all rights as a Medicaid client to a fair hearing through the Health and Human Services Commission (HHSC), in addition to the MCO's complaint and appeal process.

(d) HHSC will review the MCO's complaint and appeals procedures to determine if they comply with HHSC's standards before HHSC approves use of the procedures. Reports containing complaint summaries must be submitted to HHSC in compliance with HHSC policy.

(e) HHSC retains the authority to make the final decision following HHSC's fair hearing process.

Source Note: The provisions of this §353.415 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283