{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-137.6.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-137.6.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-137.6.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-137.6.html"}],"law_id":74118,"edition_id":1,"section_id":74118,"structure_id":15832,"section_number":"32.1-137.6","catch_line":"Complaint system","history":"1998, cc. 744, 891; 1999, cc. 643, 649; 2000, cc. 66, 657, 922; 2011, c. 788.","full_text":"A\n\nEach managed care health insurance plan licensee subject to \u00a7 32.1-137.2 shall establish and maintain for each of its managed care health insurance plans a complaint system approved by the Commissioner and the Bureau of Insurance to provide reasonable procedures for the resolution of written complaints in accordance with the requirements established under this article and Title 38.2, and shall include the following:1\n\nA record of the complaints shall be maintained for the period set forth in § 32.1-137.16 for review by the Commissioner.2\n\nEach managed care health insurance plan licensee shall provide complaint forms and\/or written procedures to be given to covered persons who wish to register written complaints. Such forms or procedures shall include the address and telephone number of the managed care licensee to which complaints shall be directed and the mailing address, telephone number, and the electronic mail address of the Office of the Managed Care Ombudsman established pursuant to § 38.2-5904 and shall also specify any required limits imposed by or on behalf of the managed care health insurance plan. Such forms and written procedures shall include a clear and understandable description of the covered person’s right to appeal adverse determinations pursuant to § 32.1-137.15.B\n\nThe Commissioner, in cooperation with the Bureau of Insurance, shall examine the complaint system. The effectiveness of the complaint system of the managed care health insurance plan licensee in allowing covered persons, or their duly authorized representatives, to have issues regarding quality of care appropriately resolved under this article shall be assessed by the State Health Commissioner under this article. Compliance by the health carrier and its managed care health insurance plans with the terms and procedures of the complaint system, as well as the provisions of Title 38.2, shall be assessed by the Bureau of Insurance.C\n\nAs part of the renewal of a certificate, each managed care health insurance plan licensee shall submit to the Commissioner and to the Office of the Managed Care Ombudsman an annual complaint report in a form agreed and prescribed by the Board and the Bureau of Insurance. The complaint report shall include, but shall not be limited to (i) a description of the procedures of the complaint system, (ii) the total number of complaints handled through the complaint system, (iii) the disposition of the complaints, (iv) a compilation of the nature and causes underlying the complaints filed, (v) the time it took to process and resolve each complaint, and (vi) the number, amount, and disposition of malpractice claims adjudicated during the year with respect to any of the managed care health insurance plan’s health care providers.\n\t\t\tThe Department of Human Resource Management and the Department of Medical Assistance Services shall file similar periodic reports with the Commissioner, in a form prescribed by the Board, providing appropriate information on all complaints received concerning quality of care and utilization review under their respective health benefits program and managed care health insurance plan licensee contractors.D\n\nThe Commissioner shall examine the complaint system under subsection B for compliance of the complaint system with respect to quality of care and shall require corrections or modifications as deemed necessary.E\n\nThe Commissioner shall have no jurisdiction to adjudicate individual controversies arising under this article.F\n\nThe Commissioner of Health or the nonprofit organization pursuant to § 32.1-276.4 may prepare a summary of the information submitted pursuant to this provision and § 32.1-122.10:01 to be included in the patient level data base.","order_by":null,"text":{"0":{"id":266526,"text":"Each managed care health insurance plan licensee subject to \u00a7 32.1-137.2 shall establish and maintain for each of its managed care health insurance plans a complaint system approved by the Commissioner and the Bureau of Insurance to provide reasonable procedures for the resolution of written complaints in accordance with the requirements established under this article and Title 38.2, and shall include the following:","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"A1"},"1":{"id":266527,"text":"A record of the complaints shall be maintained for the period set forth in § 32.1-137.16 for review by the Commissioner.","type":"section","prefixes":["A","1"],"prefix":"1","entire_prefix":"A1","prefix_anchor":"A1","level":2,"prior_prefix":"A","next_prefix":"A2"},"2":{"id":266528,"text":"Each managed care health insurance plan licensee shall provide complaint forms and\/or written procedures to be given to covered persons who wish to register written complaints. Such forms or procedures shall include the address and telephone number of the managed care licensee to which complaints shall be directed and the mailing address, telephone number, and the electronic mail address of the Office of the Managed Care Ombudsman established pursuant to § 38.2-5904 and shall also specify any required limits imposed by or on behalf of the managed care health insurance plan. Such forms and written procedures shall include a clear and understandable description of the covered person’s right to appeal adverse determinations pursuant to § 32.1-137.15.","type":"section","prefixes":["A","2"],"prefix":"2","entire_prefix":"A2","prefix_anchor":"A2","level":2,"prior_prefix":"A1","next_prefix":"B"},"3":{"id":266529,"text":"The Commissioner, in cooperation with the Bureau of Insurance, shall examine the complaint system. The effectiveness of the complaint system of the managed care health insurance plan licensee in allowing covered persons, or their duly authorized representatives, to have issues regarding quality of care appropriately resolved under this article shall be assessed by the State Health Commissioner under this article. Compliance by the health carrier and its managed care health insurance plans with the terms and procedures of the complaint system, as well as the provisions of Title 38.2, shall be assessed by the Bureau of Insurance.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A2","next_prefix":"C"},"4":{"id":266530,"text":"As part of the renewal of a certificate, each managed care health insurance plan licensee shall submit to the Commissioner and to the Office of the Managed Care Ombudsman an annual complaint report in a form agreed and prescribed by the Board and the Bureau of Insurance. The complaint report shall include, but shall not be limited to (i) a description of the procedures of the complaint system, (ii) the total number of complaints handled through the complaint system, (iii) the disposition of the complaints, (iv) a compilation of the nature and causes underlying the complaints filed, (v) the time it took to process and resolve each complaint, and (vi) the number, amount, and disposition of malpractice claims adjudicated during the year with respect to any of the managed care health insurance plan’s health care providers.\n\t\t\tThe Department of Human Resource Management and the Department of Medical Assistance Services shall file similar periodic reports with the Commissioner, in a form prescribed by the Board, providing appropriate information on all complaints received concerning quality of care and utilization review under their respective health benefits program and managed care health insurance plan licensee contractors.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"5":{"id":266531,"text":"The Commissioner shall examine the complaint system under subsection B for compliance of the complaint system with respect to quality of care and shall require corrections or modifications as deemed necessary.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"6":{"id":266532,"text":"The Commissioner shall have no jurisdiction to adjudicate individual controversies arising under this article.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"7":{"id":266533,"text":"The Commissioner of Health or the nonprofit organization pursuant to § 32.1-276.4 may prepare a summary of the information submitted pursuant to this provision and § 32.1-122.10:01 to be included in the patient level data base.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E"}},"ancestry":[{"id":15832,"edition_id":1,"name":"Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees","identifier":"1.1","label":"article","depth":3,"order_by":1,"parent_id":12728,"metadata":{},"date_created":"2026-06-26 04:00:17","date_modified":"2026-06-26 04:00:17","permalink":{"id":203095,"object_type":"structure","relational_id":15832,"identifier":"1.1","token":"32.1\/5\/1.1","url":"\/32.1\/5\/1.1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12728,"edition_id":1,"name":"Regulation of Medical Care Facilities and Services","identifier":"5","label":"chapter","depth":2,"order_by":1,"parent_id":12727,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":202855,"object_type":"structure","relational_id":12728,"identifier":"5","token":"32.1\/5","url":"\/32.1\/5\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12727,"edition_id":1,"name":"Health","identifier":"32.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":201099,"object_type":"structure","relational_id":12727,"identifier":"32.1","token":"32.1","url":"\/32.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":61229,"structure_id":15832,"section_number":"32.1-137.1","catch_line":"Definitions","url":"\/32.1-137.1\/","token":"32.1\/5\/1.1\/32.1-137.1","metadata":false},{"id":80679,"structure_id":15832,"section_number":"32.1-137.2","catch_line":"Certification of quality assurance; application; issuance; denial; renewal","url":"\/32.1-137.2\/","token":"32.1\/5\/1.1\/32.1-137.2","metadata":false},{"id":84080,"structure_id":15832,"section_number":"32.1-137.3","catch_line":"Regulations","url":"\/32.1-137.3\/","token":"32.1\/5\/1.1\/32.1-137.3","metadata":false},{"id":80091,"structure_id":15832,"section_number":"32.1-137.4","catch_line":"Examination, review or investigation","url":"\/32.1-137.4\/","token":"32.1\/5\/1.1\/32.1-137.4","metadata":false},{"id":61098,"structure_id":15832,"section_number":"32.1-137.5","catch_line":"Civil penalties; probation; suspension; restriction or prohibition of new enrollments to managed care health insurance plan licensee; revocation or nonrenewal of certificate of quality assurance; appeal process; correction","url":"\/32.1-137.5\/","token":"32.1\/5\/1.1\/32.1-137.5","metadata":false},{"id":74118,"structure_id":15832,"section_number":"32.1-137.6","catch_line":"Complaint system","url":"\/32.1-137.6\/","token":"32.1\/5\/1.1\/32.1-137.6","metadata":false}],"previous_section":{"id":61098,"structure_id":15832,"section_number":"32.1-137.5","catch_line":"Civil penalties; probation; suspension; restriction or prohibition of new enrollments to managed care health insurance plan licensee; revocation or nonrenewal of certificate of quality assurance; appeal process; correction","url":"\/32.1-137.5\/","token":"32.1\/5\/1.1\/32.1-137.5","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-137.6\/","history_text":"

This law was first created in 1998. The record of its establishment is cataloged in chapters 744<\/a> and 891<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. It has been modified 3 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 1999, chapters 643<\/a> and 649<\/a>; in 2000, chapters 66<\/a>, 657<\/a>, and 922<\/a>; in 2011, chapter 788<\/a>.<\/p>","references":[{"id":80679,"section_number":"32.1-137.2","catch_line":"Certification of quality assurance; application; issuance; denial; renewal","order_by":null,"url":"\/32.1-137.2\/"}],"refers_to":[{"id":62309,"section_number":"32.1-122.10:01","catch_line":"Expired","order_by":null,"url":"\/32.1-122.10_01\/"},{"id":74476,"section_number":"32.1-137.16","catch_line":"Records","order_by":null,"url":"\/32.1-137.16\/"},{"id":80679,"section_number":"32.1-137.2","catch_line":"Certification of quality assurance; application; issuance; denial; renewal","order_by":null,"url":"\/32.1-137.2\/"},{"id":56739,"section_number":"32.1-276.4","catch_line":"Agreements for certain data services","order_by":null,"url":"\/32.1-276.4\/"},{"id":75528,"section_number":"38.2-5904","catch_line":"Office of the Managed Care Ombudsman established; responsibilities","order_by":null,"url":"\/38.2-5904\/"}],"permalink":{"id":203117,"object_type":"law","relational_id":74118,"identifier":"32.1-137.6","token":"32.1\/5\/1.1\/32.1-137.6","url":"\/32.1-137.6\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-137.6\/","token":"32.1\/5\/1.1\/32.1-137.6","dublin_core":{"Title":"Complaint system","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-137.6","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Each managed care health insurance plan licensee subject to \u00a7 32.1-137.2<\/a> shall establish and maintain for each of its managed care health insurance plans a complaint system approved by the Commissioner<\/span> and the Bureau of Insurance to provide reasonable procedures for the resolution of written complaints in accordance with the requirements established under this article and Title 38.2, and shall include the following: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> A record of the complaints shall be maintained for the period set forth in § 32.1-137.16<\/a> for review by the Commissioner<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Each managed care health insurance plan licensee shall provide complaint forms and\/or written procedures to be given to covered persons<\/span> who wish to register written complaints. Such forms or procedures shall include the address and telephone number of the managed care licensee to which complaints shall be directed and the mailing address, telephone number, and the electronic mail address of the Office of the Managed Care Ombudsman established pursuant to § 38.2-5904<\/a> and shall also specify any required limits imposed by or on behalf of the managed care health insurance plan. Such forms and written procedures shall include a clear and understandable description of the covered person<\/span>’s right to appeal<\/span> adverse determinations pursuant to § 32.1-137.15<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The Commissioner<\/span>, in cooperation with the Bureau of Insurance, shall examine the complaint system. The effectiveness of the complaint system of the managed care health insurance plan licensee in allowing covered persons<\/span>, or their duly authorized representatives, to have issues<\/span> regarding quality of care appropriately resolved under this article shall be assessed by the State Health Commissioner<\/span> under this article. Compliance by the health carrier and its managed care health insurance plans with the terms and procedures of the complaint system, as well as the provisions of Title 38.2, shall be assessed by the Bureau of Insurance. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> As part of the renewal of a certificate, each managed care health insurance plan licensee shall submit to the Commissioner<\/span> and to the Office of the Managed Care Ombudsman an annual complaint report in a form agreed and prescribed by the Board<\/span> and the Bureau of Insurance. The complaint report shall include, but shall not be limited to (i) a description of the procedures of the complaint system, (ii) the total number of complaints handled through the complaint system, (iii) the disposition<\/span> of the complaints, (iv) a compilation of the nature and causes underlying the complaints filed, (v) the time it took to process and resolve each complaint, and (vi) the number, amount, and disposition<\/span> of malpractice claims adjudicated during the year with respect to any of the managed care health insurance plan’s health care providers.\n\t\t\tThe Department<\/span> of Human Resource Management and the Department<\/span> of Medical Assistance Services shall file similar periodic reports with the Commissioner<\/span>, in a form prescribed by the Board<\/span>, providing appropriate information on all complaints received concerning quality of care and utilization review<\/span> under their respective health benefits program and managed care health insurance plan licensee contractors. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The Commissioner<\/span> shall examine the complaint system under subsection B for compliance of the complaint system with respect to quality of care and shall require corrections or modifications as deemed necessary. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The Commissioner<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> individual controversies arising under this article. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The Commissioner<\/span> of Health or the nonprofit organization pursuant to § 32.1-276.4<\/a> may prepare a summary of the information submitted pursuant to this provision and § 32.1-122.10:01<\/a> to be included in the patient level data base. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCOMPLAINT SYSTEM (\u00a7 32.1-137.6)\n\nA. Each managed care health insurance plan licensee subject to \u00a7 32.1-137.2\nshall establish and maintain for each of its managed care health insurance plans\na complaint system approved by the Commissioner and the Bureau of Insurance to\nprovide reasonable procedures for the resolution of written complaints in\naccordance with the requirements established under this article and Title 38.2,\nand shall include the following:\n\n 1. A record of the complaints shall be maintained for the period set forth in\n § 32.1-137.16 for review by the Commissioner.\n\n 2. Each managed care health insurance plan licensee shall provide complaint\n forms and\/or written procedures to be given to covered persons who wish to\n register written complaints. Such forms or procedures shall include the\n address and telephone number of the managed care licensee to which complaints\n shall be directed and the mailing address, telephone number, and the\n electronic mail address of the Office of the Managed Care Ombudsman\n established pursuant to § 38.2-5904 and shall also specify any required\n limits imposed by or on behalf of the managed care health insurance plan. Such\n forms and written procedures shall include a clear and understandable\n description of the covered person’s right to appeal adverse\n determinations pursuant to § 32.1-137.15.\n\nB. The Commissioner, in cooperation with the Bureau of Insurance, shall examine\nthe complaint system. The effectiveness of the complaint system of the managed\ncare health insurance plan licensee in allowing covered persons, or their duly\nauthorized representatives, to have issues regarding quality of care\nappropriately resolved under this article shall be assessed by the State Health\nCommissioner under this article. Compliance by the health carrier and its\nmanaged care health insurance plans with the terms and procedures of the\ncomplaint system, as well as the provisions of Title 38.2, shall be assessed by\nthe Bureau of Insurance.\n\nC. As part of the renewal of a certificate, each managed care health insurance\nplan licensee shall submit to the Commissioner and to the Office of the Managed\nCare Ombudsman an annual complaint report in a form agreed and prescribed by the\nBoard and the Bureau of Insurance. The complaint report shall include, but shall\nnot be limited to (i) a description of the procedures of the complaint system,\n(ii) the total number of complaints handled through the complaint system, (iii)\nthe disposition of the complaints, (iv) a compilation of the nature and causes\nunderlying the complaints filed, (v) the time it took to process and resolve\neach complaint, and (vi) the number, amount, and disposition of malpractice\nclaims adjudicated during the year with respect to any of the managed care\nhealth insurance plan’s health care providers.\n\t\t\tThe Department of Human Resource Management and the Department of Medical\nAssistance Services shall file similar periodic reports with the Commissioner,\nin a form prescribed by the Board, providing appropriate information on all\ncomplaints received concerning quality of care and utilization review under\ntheir respective health benefits program and managed care health insurance plan\nlicensee contractors.\n\nD. The Commissioner shall examine the complaint system under subsection B for\ncompliance of the complaint system with respect to quality of care and shall\nrequire corrections or modifications as deemed necessary.\n\nE. The Commissioner shall have no jurisdiction to adjudicate individual\ncontroversies arising under this article.\n\nF. The Commissioner of Health or the nonprofit organization pursuant to §\n32.1-276.4 may prepare a summary of the information submitted pursuant to this\nprovision and § 32.1-122.10:01 to be included in the patient level data\nbase.\n\nHISTORY: 1998, cc. 744, 891; 1999, cc. 643, 649; 2000, cc. 66, 657, 922; 2011,\nc. 788.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}