69O-203.075. Subscriber Grievance Procedure

Every PLHSO shall have a subscriber grievance procedure, which is outlined in all master group and individual contracts as well as any certificate or member handbook provided to subscribers. Standards for the subscriber grievance procedure are as follows:

(1) Both informal and formal steps shall be available to resolve the grievance. A grievance is not considered formal until a written complaint has been received by the PLHSO;

(2) Each PLHSO shall designate a grievance coordinator who will be responsible for the implementation of the PLHSOs grievance procedure;

(3) A phone number shall be specified for the subscriber to call to present a grievance and a phone number shall be provided to enable the subscriber to contact the grievance coordinator. For entities with 25 or more employees, each phone number must be toll free or within the subscriber’s geographic area and provide reasonable access to the PLHSO without undue delays. There shall be an adequate number of phone lines to handle incoming grievances;

(4) An address shall be included for written grievances;

(5) Each level of the grievance procedure shall have some person with problem solving authority to participate in each step of the grievance procedure;

(6) The PLHSO shall process the written subscriber grievance in a reasonable length of time not to exceed 60 days. If the complaint involves the collection of information outside the service area, the PLHSO will have 30 additional days to process the subscriber complaint through all phases of the grievance procedure. A grievance which is arbitrated pursuant to Chapter 682, F.S., is permitted an additional time limitation not to exceed 270 days from the date the PLHSO is first notified of the grievance. Each PLHSO shall notify the Office of all arbitrated grievances;

(7) The subscriber grievance procedure shall state that the subscriber always has the right to file a complaint with or seek assistance from the Office;

(8) There shall be medical professional involvement in reviewing medically related grievances. Medical professional involvement shall not be limited to the subscriber’s primary care professional, but shall include another professional;

(9) If a meeting with the subscriber is necessary, the location of the meeting shall be at the administrative office of the PLHSO within the service area or at a location within the service area which is convenient to the subscriber;

(10) The PLHSO may not establish time limits of less than one year from the date of occurrence for the subscriber to file a grievance;

(11) Each PLHSO shall maintain an accurate record of each formal grievance. Each record shall include the following:

(a) A complete description of the grievance, the subscriber’s name and address, the provider’s name and address, and the PLHSO’s name and address;

(b) A complete description of the PLHSO’s findings due to the grievance procedure;

(c) A complete description of the PLHSO’s conclusion pertaining to the grievance as well as the PLHSO’s final disposition of the grievance; and,

(d) A statement as to which level of the grievance procedure the complaint has been processed and how many more levels of the grievance procedure are remaining before the complaint has been processed through the PLHSO’s entire grievance procedure.

Rulemaking Authority 636.067 FS. Law Implemented 636.016, 636.038 FS. History–New 11-15-94, Formerly 4-203.075.