HOUSE BILL No. 5572 February 12, 1998, Introduced by Reps. Schroer, Wallace, Anthony, Parks, LaForge, Baade, Bogardus, Crissman, Scott, Brater, Profit, Murphy, Hale and Gire and referred to the Committee on Insurance. A bill to amend 1956 PA 218, entitled "The insurance code of 1956," by amending section 2213 (MCL 500.2213), as added by 1996 PA 517. THE PEOPLE OF THE STATE OF MICHIGAN ENACT: 1 Sec. 2213. (1) By October 1, 1997, an insurer shall estab- 2 lish an internal formal grievance procedure for approval by the 3 insurance bureau for persons covered under a policy or certifi- 4 cate issued under chapter 34 or 36 that includes all of the 5 following: 6 (a) Provides for a designated person responsible for admin- 7 istering the grievance system. 8 (b) Provides a designated person or telephone number for 9 receiving complaints. 03595'97 a DKH 2 1 (c) Ensures full investigation of a complaint. 2 (d) Provides for timely notification to the insured as to 3 the progress of an investigation. 4 (e) Provides an insured the right to appear before the board 5 of directors or designated committee or the right to a 6 managerial-level conference to present a grievance. 7 (f) Provides for notification to the insured of the results 8 of the insurer's investigation and for advisement of the 9 insured's right to review the grievance by the commissioner. 10 (g) Provides summary data on the number and types of com- 11 plaints filed. 12 (h) Provides for periodic management and governing body 13 review of the data to assure that appropriate actions have been 14 taken. 15 (i) Provides for copies of all complaints and responses to 16 be available at the principal office of the insurer for inspec- 17 tion by the insurance bureau for 2 years following the year the 18 complaint was filed. 19 (j) That when an adverse determination is made, a written 20 statement containing the reasons for the adverse determination 21 will be provided to the insured person. 22 (k) That a written notification of the grievance procedures 23 will be provided to the insured person when the insured person 24 contests an adverse determination. 25 (l) That a final determination will be made in writing by 26 the insurer not later than 90 calendar days after a formal 27 grievance is submitted in writing by the insured person. The 03595'97 a 3 1 timing for the 90-calendar-day period may be tolled, however, for 2 any period of time the insured person is permitted to take under 3 the grievance procedure. 4 (m) That an initial determination will be made by the 5 insurer not later than 72 hours after receipt of an expedited 6 grievance. Within 3 business days after the initial determina- 7 tion by the insurer, the insured or a person, including, but not 8 limited to, a physician, authorized in writing to act on behalf 9 of the insured may request further review by the insurer or for a 10 determination of the matter by the commissioner or his or her 11 designee. If further review is requested, a final determination 12 by the insurer shall be made not later than 30 days after receipt 13 of the request for further review. Within 10 days after receipt 14 of a final determination, the insured or a person, including, but 15 not limited to, a physician, authorized in writing to act on 16 behalf of the insured may request a determination of the matter 17 by the commissioner or his or her designee. If the initial or 18 final determination by the insurer is made orally, the insurer 19 shall provide a written confirmation of the determination to the 20 insured not later than 2 business days after the oral 21 determination. An expedited grievance under this subdivision 22 applies if a grievance is submitted and a physician, orally or in 23 writing, substantiates that the time frame for a grievance under 24 subdivision (l) would acutely jeopardize the life of the 25 insured. 26 (n) That the insured person has the right to a determination 27 of the matter by the commissioner or his or her designee. 03595'97 a 4 1 (2) The commissioner shall establish a procedure for a 2 determination of a grievance under this sectionwhichTHAT 3 shall be reasonably calculated to resolve these matters infor- 4 mally and as rapidly as possible, while protecting the interests 5 of both the insured and the insurer. This procedure is not a 6 contested case under the administrative procedures act of 1969, 7Act No. 306 of the Public Acts of 1969, being sections 24.201 to824.328 of the Michigan Compiled Laws1969 PA 306, MCL 24.201 TO 9 24.328, and is not appealable underAct No. 306 of the Public10Acts of 1969THE ADMINISTRATIVE PROCEDURES ACT OF 1969, 1969 PA 11 306, MCL 24.201 TO 24.328. 12 (3) This section does not apply to a provider's complaint 13 concerning claims payment, handling, or reimbursement for health 14 care services. 15 (4) THE INSURER SHALL PROVIDE ALL INSUREDS WHO MEET THE CRI- 16 TERIA IN SECTION 7(1) OF THE EXPERIMENTAL TREATMENT DISPUTE RESO- 17 LUTION ACT WITH NOTICE OF THE INSURED'S OPTION TO HAVE THE 18 INSURER'S DENIAL OF A REQUEST FOR EXPERIMENTAL OR INVESTIGATIONAL 19 THERAPY REVIEWED. THE INSURER SHALL NOTIFY ELIGIBLE INSUREDS IN 20 WRITING OF THE OPPORTUNITY TO REQUEST AN EXTERNAL, INDEPENDENT 21 REVIEW PURSUANT TO THE EXPERIMENTAL TREATMENT DISPUTE RESOLUTION 22 ACT WITHIN 5 BUSINESS DAYS OF THE DECISION TO DENY COVERAGE. THE 23 NOTICE SHALL INCLUDE A DESCRIPTION OF THE EXTERNAL, INDEPENDENT 24 REVIEW PROCESS, THE ADDRESS OF THE EXPERIMENTAL TREATMENT DISPUTE 25 RESOLUTION COMMISSION, THE INFORMATION THE INSURED MUST PROVIDE 26 TO THE EXPERIMENTAL TREATMENT DISPUTE RESOLUTION COMMISSION UNDER 27 THE EXPERIMENTAL TREATMENT DISPUTE RESOLUTION ACT, AND NOTICE 03595'97 a 5 1 THAT THE INSURER MUST BE PROVIDED WITH NOTICE BY THE INSURED IF 2 THE INSURED WISHES TO REQUEST AN EXTERNAL, INDEPENDENT REVIEW. 3 WITHIN 5 BUSINESS DAYS OF THE INSURER'S RECEIPT OF A REQUEST BY 4 AN INSURED FOR AN EXTERNAL, INDEPENDENT REVIEW, THE INSURER SHALL 5 PROVIDE TO THE EXPERIMENTAL TREATMENT DISPUTE RESOLUTION COMMIS- 6 SION THE DOCUMENTS REQUIRED UNDER SECTION 7(2) OF THE EXPERIMEN- 7 TAL TREATMENT DISPUTE RESOLUTION ACT. 8 (5)(4)As used in this section: 9 (a) "Adverse determination" means a determination that an 10 admission, availability of care, continued stay, or other health 11 care service has been reviewed and denied. Failure to respond in 12 a timely manner to a request for a determination constitutes an 13 adverse determination. 14 (b) "Grievance" means a complaint on behalf of an insured 15 person submitted by an insured person or a person, including, but 16 not limited to, a physician, authorized in writing to act on 17 behalf of the insured person regarding: 18 (i) The availability, delivery, or quality of health care 19 services, including a complaint regarding an adverse determina- 20 tion made pursuant to utilization review. 21 (ii) Benefits or claims payment, handling, or reimbursement 22 for health care services. 23 (iii) Matters pertaining to the contractual relationship 24 between an insured and the insurer. 25 Enacting section 1. This amendatory act does not take 26 effect unless Senate Bill No. ___ or House Bill No. ___ (request 27 no. 03595'97) of the 89th Legislature is enacted into law. 03595'97 a