Iowa Admin. Code r. 191-40.9

Current through Register Vol. 47, No.14, January 8, 2025

Rule 191-40.9 - Complaints

(1) Each health maintenance organization shall provide in its bylaws for a system to resolve and record complaints.

(2) The complaint system shall provide for the resolution of the following kinds of complaints and the recording of the information required to be reported to the commissioner:

a. Complaints about the quality of health care services provided by the health maintenance organization.

b. Complaints about the availability of such services.

c. Complaints relating to enrollee participation in the operation of the health maintenance organization.

(3) The complaint system shall provide for the recording of the information required to be reported to the commissioner relative to the following kinds of complaints:

a. Complaints to the health maintenance organization concerning benefits provided by other than the health maintenance organization under the provisions of any indemnity policy or contract provided by the health maintenance organization. Such complaints shall be referred to the person providing the benefits and a copy shall be forwarded to the commissioner

b. Malpractice claims settled during the year by the health maintenance organization and any of its providers.

(4) The information required to be reported to the commissioner shall be included in the annual report to the commissioner on the form provided therewith.

(5) All complaint files shall be retained by the health maintenance organization until the examination for the period during which the complaint was received has been completed.

Iowa Admin. Code r. 191-40.9