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) Both informal and formal steps shall be available to resolve the grievance. A grievance is not considered formal until a written complaint is executed by the subscriber or completed on such forms as prescribed and received by the HMO;

(2) Each HMO shall designate at least one grievance coordinator who will be responsible for the implementation of the HMO’s grievance procedure;

(3) Phone numbers shall be specified by the HMO for the subscriber to call to present an informal grievance or to contact the grievance coordinator. Each phone number shall be toll free within the subscriber’s geographic area and provide reasonable access to the HMO without undue delays. There must 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 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;

(7) The HMO shall have physician involvement in reviewing medically related grievances. Physician involvement in the grievance process should not be limited to the subscriber’s primary care physician, but may include at least one other physician;

(8) The HMO shall offer to meet with the subscriber during the formal grievance process. The location of the meeting shall be at the administrative offices of the HMO within the service area or at a location within the service area which is convenient to the subscriber;

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

(10) Each HMO 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 HMO’s name and address,

(b) A complete description of the HMO’s factual findings and conclusions after completion of the full formal grievance procedure,

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

(d) A statement as to which levels 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 HMO’s entire grievance procedure;

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 8-15-19.