                                 CODE OF VIRGINIA

COMPLAINT SYSTEM (§ 38.2-5804)

A. A health carrier subject to subsection B of § 38.2-5801 shall establish and
maintain for each of its MCHIPs a complaint system approved by the Commission
and the State Health Commissioner to provide reasonable procedures for the
resolution of written complaints in accordance with requirements in or
established pursuant to provisions in this title and Title 32.1 and shall
include the following:

   1. A record of the complaints shall be maintained for no less than five years.

   2. Such health carrier 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 electronic mail address of the Office of the
   Managed Care Ombudsman, and shall also specify any required limits imposed by
   or on behalf of the MCHIP. Such forms and written procedures shall include a
   clear and understandable description of the covered person&#8217;s right to
   appeal adverse decisions pursuant to &#xA7; 32.1-137.15.

B. The Commission, in cooperation with the State Health Commissioner, 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 chapter shall be assessed by the State Health
Commissioner pursuant to provisions in Title 32.1 and the regulations
promulgated thereunder. 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 this title, shall be assessed by the Commission.

C. The health carrier for each MCHIP shall submit to the Office of the Managed
Care Ombudsman and the State Health Commissioner an annual complaint report in a
form prescribed by the Commission and the Board of Health. The complaint report
shall include (i) a description of the procedures of the complaint system, (ii)
the total number of complaints handled through the grievance or 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
MCHIP&#8217;s affiliated providers.

D. The provisions of this section shall not apply to plans administered by the
Department of Medical Assistance Services that provide benefits pursuant to
Title XIX or Title XXI of the Social Security Act, as amended.

E. The provisions of Chapter 5 (&#xA7; 38.2-500 et seq.) of this title shall
apply to the health carrier, its MCHIPs, and evidence of coverage and
representations thereto, except to the extent that the Commission determines
that the nature of the health carrier, its MCHIP, and evidences of coverage and
representations thereto render any of the provisions clearly inappropriate.

HISTORY: 1998, c. 891; 1999, cc. 643, 649; 2000, c. 922; 2006, c. 866.