20:06:13:72. Complaints and grievances. A Medicare select issuer must have and use procedures for hearing complaints and resolving written grievances from subscribers. Such procedures must be aimed at mutual agreement for settlement and may include arbitration procedures. Grievance procedures must meet the following requirements:
(1) The grievance procedure must be described in the policy and certificate and in the outline of coverage;
(2) At the time the policy or certificate is issued, the issuer must provide detailed information to the policyholder describing how a grievance may be registered with the issuer;
(3) The issuer must consider grievances in a timely manner and transmit them to decision-makers who have authority to investigate the issue fully and take corrective action;
(4) If a grievance is found to be valid, the issuer must take corrective action promptly;
(5) The issuer must notify all concerned parties about the results of a grievance;
(6) The issuer must report no later than March 31 each year to the director regarding its grievance procedure in a format provided by the director. The report must contain the number of grievances filed in the past year and a summary of the subject, nature, and resolution of the grievances.
Source: 22 SDR 107, effective February 18, 1996.
General Authority: SDCL 58-17A-2(5), 58-17A-2(12), 58-17A-2, 58-17A-7.
Law Implemented: SDCL 58-17A-2.
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