SECTION 13.492. Complaints; Deadlines for Response and Resolution

(a) Not later than seven calendar days after receipt of an oral or written complaint, the HCC must:

(1) acknowledge receipt of the complaint in writing;

(2) acknowledge the date of receipt; and

(3) provide a description of the HCC's complaint procedures, its appeal process for complaints filed by patients, and deadlines associated with each.

(b) An HCC must investigate each complaint received in accord with the HCC's policies and in compliance with Insurance Code §848.107 and this subchapter.

(c) After an HCC has investigated a complaint, the HCC must issue a resolution letter to the complainant not later than the 30th calendar day after the HCC receives the written complaint or the close of any hearing held under §13.493(2) of this title (relating to Rights of Physicians) that:

(1) explains the HCC's resolution of the complaint;

(2) states the specific reasons for the resolution;

(3) states the specialization of any health care provider consulted; and

(4) states, if the complainant is a patient who is dissatisfied with the resolution of the complaint, that the complainant may file an appeal of the complaint resolution, or may file a complaint with the department.

(d) In situations in which a patient complaint has been appealed, the HCC must issue a decision letter after considering the appeal that includes specific reasons for the decision and states that if the complainant is dissatisfied with the resolution of the complaint, the appeal, or the complaint process, the complainant may file a complaint with the department.

(e) An HCC must maintain a complaint log that captures each complaint by category, including at least the following:

(1) quality of care or services;

(2) accessibility and availability of services, providers, or both;

(3) complaint procedures;

(4) physician and provider contracts;

(5) claims processing and bill payment disputes; and

(6) miscellaneous.

(f) Each HCC must maintain the complaint log required under subsection (e) of this section and documentation on each complaint, complaint proceeding, and action taken on the complaint until the third anniversary after the date the complaint was received.

Source Note: The provisions of this §13.492 adopted to be effective March 31, 2013, 38 TexReg 2100