DEPARTMENT OF FINANCIAL SERVICES
RULE NO.:RULE TITLE:
69O-191.078Subscriber Grievance Procedure
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 45 No. 56, March 21, 2019 issue of the Florida Administrative Register.
The changes are in response to written comments received from the Joint Administrative Procedures Committee.
69O-191.078 Subscriber Grievance Procedure.
Every HMO shall have a subscriber grievance procedure. A detailed description of the HMO’s subscriber grievance procedure shall be included in all group and individual contracts as well as in any certificate or member handbook provided to subscribers. This procedure shall be administered at no cost to the subscriber. An HMO subscriber grievance procedure must include the following:
(1) through (5) No change.
(6) The HMO shall process the formal written subscriber grievance in a reasonable length of time not to exceed 60 days, unless the subscriber and HMO mutually agree to extend the time frame set forth by this rule. If the complaint involves the collection of information outside the service area, the HMO will have 30 additional days to process the subscriber complaint through all phases of the grievance procedure. The time limitations prescribed in this paragraph requiring completion of the grievance process within 60 days shall be tolled after the HMO has notified the subscriber, in writing, that additional information is required in order to properly complete review of the complaint. Upon receipt by the HMO of the additional information requested, the time for completion of the grievance process set forth herein shall resume. A grievance which is arbitrated pursuant to chapter 682, F.S., is permitted an additional time limitation not to exceed 210 days from the date the HMO receives a written request for arbitration from the subscriber; . Each HMO shall notify the Office of all arbitrated grievances on the quarterly grievance report required by subsection 69O-191.078 (11) , F.A.C.;
(7) through (10) No change.
(11) Each HMO shall submit a quarterly report to the Office pursuant to section 641.311(1)(b), F.S., listing the number and nature of all formal subscriber grievances which have not been resolved to the satisfaction of the subscriber, after the subscriber has utilized the full grievance procedure of the HMO. This report shall be formatted as outlined in the quarterly report of subscriber grievances form incorporated herein by reference and shall be filed with the Office no later than 45 days after the end of each calendar quarter. Quarterly report of subscriber grievance forms can be obtained from the Office of Insurance Regulation’s website: http://www.floir.com/iportal.
Rulemaking Authority 641.36 FS. Law Implemented 641.22(9), 641.31(5) FS. History–New 7-8-87, Amended 2-22-88, 10-25-89, Formerly 4-31.078, Amended 5-28-92, Formerly 4-191.078, Amended ____________.
