3 Alaska Admin. Code § 28.932

Current through September 25, 2024

Section 3 AAC 28.932 - Grievance reporting; recordkeeping requirements

(a) A health care insurer shall maintain a written calendar year register, in a manner that is reasonably clear and accessible to the director, to document

(1) each grievance received;

(2) a general description of the reason for the grievance;

(3) the date the grievance was received;

(4) the date of each review;

(5) resolution of the grievance;

(6) the date of resolution;

(7) the name of the covered person for whom the grievance was filed;

(8) the health care insurer's review of each grievance;

(9) notices and claims associated with each grievance;

(10) each request for a review of a grievance involving an adverse determination; and

(11) evidence sufficient to document compliance with this section.

(b) A health care insurer shall make the records maintained under (a) of this section available to the following upon request:

(1) the covered person or the covered person's authorized representative;

(2) the director;

(3) an applicable federal oversight agency.

(c) Except under (d) of this section, a health care insurer shall retain a calendar year register for the longer of the following periods:

(1) three years; or

(2) until the director has adopted a final report of an examination that contains a review of the register for that calendar year.

(d) Notwithstanding (c) of this section, a health care insurer shall retain for six years calendar year register records of a claim filed, and notice provided, under 3 AAC 28.936(o) and 3 AAC 28.938(h).

(e) A health care insurer shall submit to the director a calendar year annual report in a format approved by the director. The report must include for each type of health care insurance policy offered by the health care insurer

(1) a certificate of compliance stating the health care insurer has established and maintains, for each health care insurance policy, grievance procedures that fully comply with 3 AAC 28.930 - 3 AAC 28.938;

(2) the number of covered lives;

(3) the total number of grievances;

(4) the number of grievances resolved and their resolution;

(5) the number of grievances appealed to the director of which the health care insurer is aware;

(6) the number of grievances referred to alternative dispute resolution procedures or resulting in litigation; and

(7) a synopsis of actions being taken by the health care insurer to correct problems identified by the health care insurer or the division during a grievance.

3 AAC 28.932

Eff. 3/15/2018,Register 225, April 2018

Authority:AS 21.06.090

AS 21.07.005