                                 CODE OF VIRGINIA

COMPLAINT SYSTEM (§ 32.1-137.6)

A. Each managed care health insurance plan licensee subject to § 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. A record of the complaints shall be maintained for the period set forth in
   &#xA7; 32.1-137.16 for review by the Commissioner.

   2. 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 &#xA7; 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&#8217;s right to appeal adverse
   determinations pursuant to &#xA7; 32.1-137.15.

B. 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.

C. 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&#8217;s health care providers.
			The 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. 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.

E. The Commissioner shall have no jurisdiction to adjudicate individual
controversies arising under this article.

F. The Commissioner of Health or the nonprofit organization pursuant to &#xA7;
32.1-276.4 may prepare a summary of the information submitted pursuant to this
provision and &#xA7; 32.1-122.10:01 to be included in the patient level data
base.

HISTORY: 1998, cc. 744, 891; 1999, cc. 643, 649; 2000, cc. 66, 657, 922; 2011,
c. 788.