Common use of Member Complaint Process Clause in Contracts

Member Complaint Process. 8.5.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this contract and in applicable federal law. The complaint and appeals procedure must be the same for all Members and must comply with Texas Insurance Code, Article 20A. 12 or applicable federal law. Modifications and amendments must be submitted to TDH at least 30 days prior to the implementation of the modification or amendment. 8.5.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDH. Any changes or modifications to the procedures must be submitted to TDH for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization. 8.5.4 HMO must have a routine process to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaints. HMO must cooperate with TDH and TDH's Enrollment Broker in Member complaints relating to enrollment and disenrollment. 8.5.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints. 8.5.6 HMO's process must require that every complaint received in person, by telephone or in writing, is recorded in a written record and is logged with the following details: date; identification of the individual filing the complaint; identification of the individual recording the complaint; nature of the complaint; disposition of the complaint; corrective action required; and date resolved. 8.5.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 HMO is prohibited from discriminating against a Member because that Member is making or has made a complaint. 8.5.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH within five (5) business days after the Member makes a disenrollment request. 8.5.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating to the utilization review, except where otherwise provided in this contract and in applicable federal law. The appeal of an adverse determination procedure must be the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determination. 8.5.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH Fair Hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH Fair Hearing process. 8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements (Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.) require the agency to make a final decision after a fair hearing, which conflicts with the State requirement that the IRO make a final decision. Therefore, the State requirement is pre-empted by the federal requirement. 8.5.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH internal complaint committees. 8.5.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination.

Member Complaint Process. 8.5.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this contract and in applicable federal law. The complaint and appeals procedure must be the same for all Members members and must comply with Texas Insurance Code, Article 20A. 12 20A.12 or applicable federal law. Modifications and amendments must be submitted to TDH at least 30 days prior to the implementation of the modification or amendment. 8.5.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDHTDH before Phase I of Readiness Renewal Review. Any changes or modifications to the procedures must be submitted to TDH for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization.. 37 May 31, 2001 8.5.4 HMO must have a routine process to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaints. HMO must cooperate with TDH and TDH's Enrollment Broker in Member complaints relating to enrollment and disenrollment. 8.5.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints. 8.5.6 HMO's process must require that every complaint received in person, by telephone or in writing, is recorded in a written record and is logged with the following details: date; identification of the individual filing the complaint; identification of the individual recording the complaint; nature of the complaint; disposition of the complaint; corrective action required; and date resolved. 8.5.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 HMO is prohibited from discriminating against a Member because that Member is making or has made a complaint. 8.5.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH within five (5) business days after the Member makes a disenrollment request. 8.5.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating to the utilization review, except where otherwise provided in this contract and in applicable federal law. The appeal of an adverse determination procedure must be the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determination. 8.5.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH Fair Hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH Fair Hearing process. 8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements regulations (Social Security Act Section 1902a(3ss.1902a(3), codified at 42 C.F.R. 431.200 et. et seq.) require the agency to make a final decision after a fair hearingFair Hearing, which conflicts with the State requirement that the IRO make a final decision. Therefore, the State requirement is pre-empted by the federal requirement. 8.5.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH internal complaint committees. 8.5.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination.. 39 May 31, 2001

Member Complaint Process. 8.5.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this contract and in applicable federal law. The complaint and appeals procedure must be the same for all Members and must comply with Texas Insurance Code, Article 20A. 12 20A.12 or applicable federal law. Modifications and amendments must be submitted to TDH at least 30 days prior to the implementation of the modification or amendment. 8.5.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDH. Any changes or modifications to the procedures must be submitted to TDH for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization. 8.5.4 HMO must have a routine process to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaints. HMO must cooperate with TDH and TDH's Enrollment Broker in Member complaints relating to enrollment and disenrollment. 8.5.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints. 8.5.6 HMO's process must require that every complaint received in person, by telephone or in writing, is recorded in a written record and is logged with the following details: date; identification of the individual filing the complaint; identification of the individual recording the complaint; nature of the complaint; disposition of the complaint; corrective action required; and date resolved. 8.5.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 HMO is prohibited from discriminating against a Member because that Member is making or has made a complaint. 8.5.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH within five (5) business days after the Member makes a disenrollment request. 8.5.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating to the utilization review, except where otherwise provided in this contract and in applicable federal law. The appeal of an adverse determination procedure must be the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determination. 8.5.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH Fair Hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH Fair Hearing process. 8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements (Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.) require the agency to make a final decision after a fair hearing, which conflicts with the State requirement that the IRO make a final decision. Therefore, the State requirement is pre-empted by the federal requirement. 8.5.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH internal complaint committees. 8.5.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination.

Member Complaint Process. 8.5.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this contract and in applicable federal law. The complaint and appeals procedure must be the same for all Members and must comply with Texas Insurance Code, Article 20A. 12 20A.12 or applicable federal law. Modifications and amendments must be submitted to TDH HHSC at least 30 days prior to the implementation of the modification or amendment. 8.5.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDHHHSC. Any changes or modifications to the procedures must be submitted to TDH HHSC for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization. 8.5.4 HMO must have a routine process to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaints. HMO must cooperate with TDH HHSC and TDHHHSC's Enrollment Broker in Member complaints relating to enrollment and disenrollment. 8.5.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints. 8.5.6 HMO's process must require that every complaint received in person, by telephone or in writing, is recorded in a written record and is logged with the following details: date; identification of the individual filing the complaint; identification of the individual recording the complaint; nature of the complaint; disposition of the complaint; corrective action required; and date resolved. 8.5.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 HMO is prohibited from discriminating against a Member because that Member is making or has made a complaint. 8.5.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH HHSC within five (5) business days after the Member makes a disenrollment request.. STAR+PLUS BBA Amendment STAR+PLUS BBA Amendment Health and Human Services Commission 8.5.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating to the utilization review, except where otherwise provided in this contract and in applicable federal law. The appeal of an adverse determination procedure must be the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH HHSC no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determination. 8.5.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH HHSC Fair Hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH HHSC Fair Hearing process. 8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements (Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.) require the agency to make a final decision after a fair hearing, which conflicts with the State requirement that the IRO make a final decision. Therefore, the State requirement is pre-empted preempted by the federal requirement. 8.5.14 HMO will cooperate with the Enrollment Broker and TDH HHSC to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH HHSC internal complaint committees. 8.5.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination.

Member Complaint Process. 8.5.1 8.6.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this 1999 Renewal Contract Harrxx Xxxvice Area 92 August 9, 1999 contract and in applicable federal law. The complaint and appeals procedure must be the same for all Members and must comply with Texas Insurance Code, Article 20A. 12 20A.12 or applicable federal law. Modifications and amendments must be submitted to TDH at least 30 days prior to the implementation of the modification or amendment. 8.5.2 8.6.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDH. Any changes or modifications to the procedures must be submitted to TDH for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 8.6.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization. 8.5.4 8.6.4 HMO must have a routine process to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaints. HMO must cooperate with TDH and TDH's Enrollment Broker in Member complaints relating to enrollment and disenrollment. 8.5.5 8.6.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints. 8.5.6 8.6.6 HMO's process must require that every complaint received in person, by telephone or in writing, is recorded in a written record and is logged with the following details: date; identification of the individual filing the complaint; identification of the individual recording the complaint; nature of the complaint; disposition of the complaint; corrective action required; and date resolved. 8.5.7 8.6.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 8.6.8 HMO is prohibited from discriminating against a Member because that 1999 Renewal Contract Harrxx Xxxvice Area 93 August 9, 1999 Member is making or has made a complaint. 8.5.9 8.6.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH within five (5) business days after the Member makes a disenrollment request. 8.5.10 8.6.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating to the utilization review, except where otherwise provided in this contract and in applicable federal law. The appeal of an adverse determination procedure must be the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determination. 8.5.11 8.6.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH Fair Hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 8.6.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH Fair Hearing process. 8.5.13 8.6.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements (Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.) require the agency to make a final decision after a fair hearing, which conflicts with the State requirement that the IRO make a final decision. Therefore, the State requirement is pre-empted by the federal 1999 Renewal Contract Harrxx Xxxvice Area 94 August 9, 1999 requirement. 8.5.14 8.6.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH internal complaint committees. 8.5.15 8.6.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 8.6.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination. 8.6.17 HMO's Member Advocates must assist Members in writing or filing a complaint or appeal of an adverse determination and monitoring the complaint or appeal through the Contractor's complaint or appeal of an adverse determination process until the issue is resolved.

Member Complaint Process. 8.5.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this contract and in applicable federal law. The complaint and appeals procedure must be the same for all Members members and must comply with Texas Insurance Code, Article 20A. 12 20A.12 or applicable federal law. Modifications and amendments must be submitted to TDH at least 30 days prior to the implementation of the modification or amendment. 8.5.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDHTDH before Phase I of Readiness Renewal Review. Any changes or modifications to the procedures must be submitted to TDH for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization. 37 May 31, 2001 8.4.1 A Medicaid Identification Form (Form 3087) is issued monthly by the TDHS. The form includes the "STAR" Program logo and the name and toll free number of the Member's health plan. A Member may have a temporary Medicaid Identification (Form 1027-A) which will include a STAR indicator. 8.5.4 8.4.2 HMO must have issue a routine process Member Identification Card (ID) to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaintsMember within five (5) days from receiving the Enrollment File from the Enrollment Broker. HMO must cooperate with TDH and TDH's Enrollment Broker in Member complaints relating to enrollment and disenrollment. 8.5.5 HMO's complaint procedures If the 5th day falls on a weekend or state holiday, the ID Card must be provided to Members in writing issued by the following working day. The ID Card must include, at a minimum, the following: Member's name; Member's Medicaid number; either the issue date of the card or effective date of the PCP assignment; PCP's name, address, and in alternative communication formats. A written description telephone number; name of HMO; name of IPA to which the Member's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include PCP belongs, if applicable; the 24-hour, seven (7) day a written description in the Member Handbook. HMO must maintain at least one local and one week toll-free telephone number operated by HMO; the toll-free number for making complaints. 8.5.6 HMO's process behavioral health care services; and directions for what to do in an emergency. The ID Card must require that every complaint received in personbe reissued if the Member reports a lost card, by telephone there is a Member name change, if Member requests a new PCP, or in writing, is recorded for any other reason which results in a written record and is logged with the following details: date; identification of the individual filing the complaint; identification of the individual recording the complaint; nature of the complaint; disposition of the complaint; corrective action required; and date resolved. 8.5.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 HMO is prohibited from discriminating against a Member because that Member is making or has made a complaint. 8.5.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH within five (5) business days after the Member makes a disenrollment request. 8.5.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating change to the utilization review, except where otherwise provided in this contract and in applicable federal law. The appeal of an adverse determination procedure must be information disclosed on the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determinationID Card. 8.5.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH Fair Hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH Fair Hearing process. 8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements (Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.) require the agency to make a final decision after a fair hearing, which conflicts with the State requirement that the IRO make a final decision. Therefore, the State requirement is pre-empted by the federal requirement. 8.5.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH internal complaint committees. 8.5.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination.

Member Complaint Process. 8.5.1 8.6.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this contract and in applicable federal law. The complaint and appeals procedure must be the same for all Members and must comply with Texas Insurance Code, Article 20A. 12 20A.12 or applicable federal law. Modifications and amendments must be submitted to TDH at least 30 days prior to the implementation of the modification or amendment. 8.5.2 8.6.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDH. Any changes or modifications to the procedures must be submitted to TDH for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 8.6.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization. 8.5.4 8.6.4 HMO must have a routine process to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaints. HMO must cooperate 1999 Renewal Contract Tarrant Service Area 92 August 9, 1999 93 with TDH and TDH's Enrollment Broker in Member complaints relating to enrollment and disenrollment. 8.5.5 8.6.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints. 8.5.6 8.6.6 HMO's process must require that every complaint received in person, by telephone or in writing, is recorded in a written record and is logged with the following details: date; identification of the individual filing the complaint; identification of the individual recording the complaint; nature of the complaint; disposition of the complaint; corrective action required; and date resolved. 8.5.7 8.6.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 8.6.8 HMO is prohibited from discriminating against a Member because that Member is making or has made a complaint. 8.5.9 8.6.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH within five (5) business days after the Member makes a disenrollment request. 8.5.10 8.6.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating to the utilization review, except where otherwise provided in this contract and in applicable federal law. The appeal of an adverse determination procedure must be the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determination. 8.5.11 8.6.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or 1999 Renewal Contract Tarrant Service Area 93 August 9, 1999 94 a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH Fair Hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 8.6.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH Fair Hearing process. 8.5.13 8.6.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements (Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.) require the agency to make a final decision after a fair hearing, which conflicts with the State requirement that the IRO make a final decision. Therefore, the State requirement is pre-empted by the federal requirement. 8.5.14 8.6.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH internal complaint committees. 8.5.15 8.6.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 8.6.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination.

Member Complaint Process. 8.5.1 HMO must develop, implement and maintain a Member complaint system that complies with the requirements of Article 20A.12 of the Texas Insurance Code, relating to the Complaint System, except where otherwise provided in this contract and or in applicable federal law. The complaint and appeals procedure must be the same for all Members and must comply with the Texas Insurance Code, Article 20A. 12 20A.12 or applicable federal law. Modifications and amendments must be submitted to TDH at least 30 days prior to the implementation of the modification or amendment. 8.5.2 HMO must have written policies and procedures for receiving, tracking, reviewing, and reporting and resolving of Member complaints. The procedures must be reviewed and approved in writing by TDH. Any changes or modifications to the 80 Dallas Service Area Contract 87 procedures must be submitted to TDH for approval thirty (30) days prior to the effective date of the amendment. 8.5.3 HMO must designate an officer of HMO who has primary responsibility for ensuring that complaints are resolved in compliance with written policy and within the time required. An "officer" of HMO means a president, vice president, secretary, treasurer, or chairperson of the board for a corporation, the sole proprietor, the managing general partner of a partnership, or a person having similar executive authority in the organization. 8.5.4 HMO must have a routine process to detect patterns of complaints and disenrollments and involve management and supervisory staff to develop policy and procedural improvements to address the complaints. HMO must cooperate with TDH and TDH's Enrollment Broker enrollment broker in addressing Member complaints relating to enrollment and disenrollment. 8.5.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication communications formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description of the complaint procedures in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints. 8.5.6 HMO's process must require that every complaint received in person, by telephone or in writing, is recorded in a written record and is logged with the following details: date; , identification of the individual filing the complaint; , identification of the individual recording the complaint; , nature of the complaint; disposition of the complaint; , corrective action required; , and date resolved. 8.5.7 HMO's process must include a requirement that the Governing Body of HMO reviews the written records (logs) for complaints and appeals. 8.5.8 HMO is prohibited from discriminating against a Member because that Member is making or has made a complaint. 8.5.9 HMO cannot process requests for disenrollments through HMO's complaint procedures. Requests for disenrollments must be referred to TDH within five (5) business days after the Member makes a disenrollment request. 8.5.10 HMO must develop, implement and maintain an appeal of adverse determination procedure that complies with the requirements of Article 21.58A of the Texas Insurance Code, relating to the utilization review, except where otherwise provided in this their contract and in applicable federal law. The appeal of an adverse 81 Dallas Service Area Contract 88 determination procedure must be the same for all Members and must comply with Texas Insurance Code, Article 21.58A or applicable federal law. Modifications and amendments must be submitted to TDH no less than 30 days prior to the implementation of the modification or amendment. When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, HMO or UR agent must regard the expression of dissatisfaction as a request to appeal an adverse determination. 8.5.11 If a complaint or appeal of an adverse determination relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform Members they have the right to access the TDH Fair Hearing fair hearing process at any time in lieu of the internal complaint system provided by HMO. HMO is required to comply with the requirements contained in 1 TAC Chapter 357, relating to notice and Fair Hearings fair hearings in the Medicaid program, whenever an action is taken to deny, delay, reduce, terminate or suspend a covered service. 8.5.12 If Members utilize HMO's internal complaint or appeal of adverse determination system and the complaint relates to the denial, delay, reduction, termination or suspension of covered services by either HMO or a utilization review agent contracted to perform utilization review by HMO, HMO must inform the Member that they continue to have a right to appeal the decision through the TDH Fair Hearing fair hearing process. 8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a Member's right to appeal an adverse determination made by HMO or a utilization review agent by an independent review organization, do not apply to a Medicaid recipient. Federal fair hearing requirements (Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.) require the agency to make a final decision decision, after a fair hearing, hearing which conflicts with the State requirement that the IRO make a final decision. Therefore, therefore the State requirement is pre-empted by the federal requirement. 8.5.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all Member complaints. Such cooperation may include, but is not limited to, participation by HMO or Enrollment Broker and/or TDH internal complaint committees. 8.5.15 HMO must have policies and procedures in place outlining the role of HMO's Medical Director in the Member Complaint System and appeal of an adverse determination. The Medical Director must have a significant role in monitoring, investigating and hearing complaints. 8.5.16 HMO must provide Member Advocates to assist Members in understanding and using HMO's complaint system and appeal of an adverse determination.