NAC695D.510. Requirements for approval.

To obtain approval of a system for resolving complaints of members concerning services covered by an organization from the Commissioner as required pursuant to NAC 695D.500, an organization must:

     1. Demonstrate that the system will resolve oral and written complaints concerning:

     (a) Payment or reimbursement for covered services;

     (b) The availability, delivery or quality of covered services, including, without limitation, adverse determinations made pursuant to utilization review; and

     (c) The terms and conditions of the policies of a member.

     2. Submit to the Division:

     (a) The name and title of the employee responsible for the system;

     (b) A description of the procedure used to notify a member of the decision regarding his or her complaint; and

     (c) A copy of the explanation of rights and procedures which is to be provided to members pursuant to NAC 695D.520.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)