NAC687B.370. Procedures for hearing complaints and resolving grievances.

     1. A Medicare select issuer shall have written procedures for hearing complaints and resolving written grievances made by policyholders and certificate holders under a Medicare select policy or certificate. The procedures may include the utilization of arbitration if the Medicare select issuer and the policyholder or certificate holder or the policyholder’s or certificate holder’s spouse mutually agree to use it.

     2. The procedure for addressing grievances must be described in all policies and certificates and in the outline of coverage provided to applicants for coverage pursuant to NAC 687B.368.

     3. The Medicare select issuer shall provide detailed information to the policyholder or certificate holder at the time the policy or certificate is issued that describes how to file a grievance with the Medicare select issuer.

     4. The Medicare select issuer shall begin evaluating a grievance filed with it within 10 working days after the filing date by transmitting the grievance to the person who has authority to investigate the issue fully and take corrective action to address it.

     5. If a grievance is found to be valid, corrective action must commence within 48 hours after the determination or within 72 hours after the determination if a holiday occurs within the 48-hour period.

     6. All concerned parties must be notified of the determination made with regard to the grievance.

     7. The Medicare select issuer shall report to the Commissioner no later than March 31 of each year regarding its grievance procedure. The report must contain the number of grievances filed in the past year and a summary of the nature and resolution of those grievances.

     (Added to NAC by Comm’r of Insurance, eff. 5-13-96)