Sec. 843.253. COMPLAINT INVESTIGATION AND RESOLUTION. (a) A health maintenance organization shall investigate each complaint received in accordance with the health maintenance organization's policies and in compliance with this chapter.
(b) After a health maintenance organization has investigated a complaint, the health maintenance organization shall issue a response letter to the complainant within the time prescribed by Section 843.252(c) that:
(1) explains the health maintenance organization's resolution of the complaint;
(2) states the specific medical and contractual reasons for the resolution;
(3) states the specialization of any physician or other provider consulted; and
(4) contains a complete description of the process for appeal, including the deadlines for the appeals process and the deadlines for the final decision on the appeal.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Structure Texas Statutes
Title 6 - Organization of Insurers and Related Entities
Subtitle C - Life, Health, and Accident Insurers and Related Entities
Chapter 843 - Health Maintenance Organizations
Subchapter G. Dispute Resolution
Section 843.251. Complaint System Required; Commissioner Rules and Examination
Section 843.252. Complaint Initiation and Initial Response; Deadlines for Response and Resolution
Section 843.253. Complaint Investigation and Resolution
Section 843.254. Appeal to Complaint Appeal Panel; Deadlines
Section 843.255. Composition of Complaint Appeal Panel
Section 843.256. Information Provided to Complainant Relating to Complaint Appeal Panel
Section 843.257. Rights of Complainant at Complaint Appeal Panel Meeting
Section 843.258. Appeal Involving Ongoing Emergency or Continued Hospitalization
Section 843.259. Notice of Decision on Appeal
Section 843.260. Record of Complaints
Section 843.261. Special Provisions for Appeals of Adverse Determinations