HOUSE BILL No. 5574 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 1980 PA 350, entitled "The nonprofit health care reform act," by amending section 404 (MCL 550.1404), as amended by 1996 PA 516. THE PEOPLE OF THE STATE OF MICHIGAN ENACT: 1 Sec. 404. (1) A person who has reason to believe that a 2 health care corporation has violated section 402 or 403, if the 3 violation was with respect to an action or inaction of the corpo- 4 ration with respect to that person, is entitled to a private 5 informal managerial-level conference with the corporation, and to 6 a review before the commissioner or his or her designee if the 7 conference fails to resolve the dispute. 8 (2) A health care corporation shall establish reasonable 9 internal procedures to provide a person with a private informal 10 managerial-level conference as provided in subsection (1). This 03595'97 c DKH 2 1 procedure shall provide that a final determination will be made 2 in writing by the health care corporation not later than 90 cal- 3 endar days after a grievance is submitted in writing by the 4 member or person, including, but not limited to, a physician, 5 authorized in writing to act on behalf of the member. The timing 6 for the 90-calendar-day period may be tolled, however, for any 7 period of time the member is permitted to take under the griev- 8 ance procedure. These procedures shall include all of the 9 following: 10 (a) A method of providing the person, upon request and pay- 11 ment of a reasonable copying charge, with information pertinent 12 to the denial of a certificate or to the rate charged. 13 (b) A method for resolving the dispute promptly and infor- 14 mally, while protecting the interests of both the person and the 15 corporation. 16 (3) If the health care corporation fails to provide a con- 17 ference and proposed resolution within 30 days after a request by 18 a person, or if the person disagrees with the proposed resolution 19 of the corporation after completion of the conference, the person 20 is entitled to a determination of the matter by the commissioner 21 or his or her designee. 22 (4) By October 1, 1997, a health care corporation shall 23 establish, as part of its internal procedures, an expedited 24 grievance procedure. The expedited grievance procedure shall 25 provide that an initial determination will be made by the health 26 care corporation not later than 72 hours after receipt of the 27 grievance. Within 3 business days after the initial 03595'97 c 3 1 determination by the health care corporation, the member or a 2 person, including, but not limited to, a physician, authorized in 3 writing to act on behalf of the member may request further review 4 by the health care corporation or for a determination of the 5 matter by the commissioner or his or her designee under this 6 section. If further review is requested, a final determination 7 by the health care corporation shall be made not later than 8 30 days after receipt of the request for further review. Within 9 10 days after receipt of a final determination, the member or a 10 person, including, but not limited to, a physician, authorized in 11 writing to act on behalf of the member may request a determina- 12 tion of the matter by the commissioner or his or her designee 13 under this section. If the initial or final determination by the 14 health care corporation is made orally, the health care corpora- 15 tion shall provide a written confirmation of the determination to 16 the member not later than 2 business days after the oral 17 determination. An expedited grievance under this subsection 18 applies if a grievance is submitted and a physician, orally or in 19 writing, substantiates that the time frame for a grievance under 20 subsections (1) to (3) would acutely jeopardize the life of the 21 member. This subsection does not apply to a provider's complaint 22 concerning claims payment, handling, or reimbursement for health 23 care services. As used in this subsection, "grievance" means an 24 oral or written statement, by a member or a person, including, 25 but not limited to, a physician, authorized in writing to act on 26 behalf of the member, to the health care corporation that the 03595'97 c 4 1 health care corporation has wrongfully refused or failed to 2 respond in a timely manner to a request for benefits or payment. 3 (5) The commissioner shall by rule establish a procedure for 4 determination under this section, which shall be reasonably cal- 5 culated to resolve these matters informally and as rapidly as 6 possible, while protecting the interests of both the person and 7 the health care corporation. 8 (6) If either the health care corporation or the person dis- 9 agrees with a determination of the commissioner or his or her 10 designee under this section, the commissioner or his or her des- 11 ignee, if requested to do so by either party, shall proceed to 12 hear the matter as a contested case under the administrative pro- 13 cedures act. 14 (7) THE HEALTH CARE CORPORATION SHALL PROVIDE ALL MEMBERS 15 WHO MEET THE CRITERIA IN SECTION 7(1) OF THE EXPERIMENTAL TREAT- 16 MENT DISPUTE RESOLUTION ACT WITH NOTICE OF THE MEMBER'S OPTION TO 17 HAVE THE HEALTH CARE CORPORATION'S DENIAL OF A REQUEST FOR EXPER- 18 IMENTAL OR INVESTIGATIONAL THERAPY REVIEWED. THE HEALTH CARE 19 CORPORATION SHALL NOTIFY ELIGIBLE MEMBERS IN WRITING OF THE 20 OPPORTUNITY TO REQUEST AN EXTERNAL, INDEPENDENT REVIEW PURSUANT 21 TO THE EXPERIMENTAL TREATMENT DISPUTE RESOLUTION ACT WITHIN 5 22 BUSINESS DAYS OF THE DECISION TO DENY COVERAGE. THE NOTICE SHALL 23 INCLUDE A DESCRIPTION OF THE EXTERNAL, INDEPENDENT REVIEW PRO- 24 CESS, THE ADDRESS OF THE EXPERIMENTAL TREATMENT DISPUTE RESOLU- 25 TION COMMISSION, THE INFORMATION THE MEMBER MUST PROVIDE TO THE 26 EXPERIMENTAL TREATMENT DISPUTE RESOLUTION COMMISSION UNDER THE 27 EXPERIMENTAL TREATMENT DISPUTE RESOLUTION ACT, AND NOTICE THAT 03595'97 c 5 1 THE HEALTH CARE CORPORATION MUST BE PROVIDED WITH NOTICE BY THE 2 MEMBER IF THE MEMBER WISHES TO REQUEST AN EXTERNAL, INDEPENDENT 3 REVIEW. WITHIN 5 BUSINESS DAYS OF THE HEALTH CARE CORPORATION'S 4 RECEIPT OF A REQUEST BY A MEMBER FOR AN EXTERNAL, INDEPENDENT 5 REVIEW, THE HEALTH CARE CORPORATION SHALL PROVIDE TO THE EXPERI- 6 MENTAL TREATMENT DISPUTE RESOLUTION COMMISSION THE DOCUMENTS 7 REQUIRED UNDER SECTION 7(2) OF THE EXPERIMENTAL TREATMENT DISPUTE 8 RESOLUTION ACT. 9 Enacting section 1. This amendatory act does not take 10 effect unless Senate Bill No. ___ or House Bill No. ___ (request 11 no. 03595'97) of the 89th Legislature is enacted into law. 03595'97 c Final page. DKH