SENATE BILL NO. 958 March 3, 1998, Introduced by Senators BOUCHARD and SHUGARS and referred to the Committee on Health Policy and Senior Citizens. A bill to amend 1980 PA 350, entitled "The nonprofit health care corporation 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. IN ADDITION, A PROVIDER 8 WHO HAS REASON TO BELIEVE THAT A HEALTH CARE CORPORATION HAS 9 VIOLATED SECTION 402, 403, OR ANY OTHER PROVISION OF THIS ACT AND 10 WHO MAY BE ADVERSELY AFFECTED BY THE ALLEGED VIOLATION OR WHO HAS 05140'97 DKH 2 1 A DISPUTE WITH THE CORPORATION OVER ANY MATTER THAT THE 2 CORPORATION CONSIDERS TO BE A MATTER OF POLICY INCLUDING ISSUES 3 PERTAINING TO REIMBURSEMENT METHODOLOGIES, RATES, AND PROCEDURES 4 IS ENTITLED TO A PRIVATE INFORMAL MANAGERIAL-LEVEL CONFERENCE 5 WITH THE CORPORATION, AND TO A REVIEW BEFORE THE COMMISSIONER OR 6 HIS OR HER DESIGNEE IF THE CONFERENCE FAILS TO RESOLVE THE 7 DISPUTE. AN AGREEMENT BETWEEN A HEALTH CARE CORPORATION AND A 8 PERSON THAT ATTEMPTS TO WAIVE THE RIGHTS PROVIDED UNDER THIS SUB- 9 SECTION IS UNENFORCEABLE. 10 (2) A health care corporation shall establish reasonable 11 internal procedures to provide a person with a private informal 12 managerial-level conference as provided in subsection (1). This 13 procedure shall provide that a final determination will be made 14 in writing by the health care corporation not later than 90 cal- 15 endar days after a grievance is submitted in writing by the 16 member or person, including, but not limited to, a physician, 17 authorized in writing to act on behalf of the member. The timing 18 for the 90-calendar-day period may be tolled, however, for any 19 period of time the member OR PERSON is permitted to take under 20 the grievance procedure. These procedures shall include all of 21 the following: 22 (a) A method of providing the person, upon request and pay- 23 ment of a reasonable copying charge, with information pertinent 24 to the denial of a certificate or to the rate charged. 25 (b) A method for resolving the dispute promptly and infor- 26 mally, while protecting the interests of both the person and the 27 corporation. 05140'97 3 1 (3) If the health care corporation fails to provide a 2 conference and proposed resolution within 30 days after a request 3 by a person, or if the person disagrees with the proposed resolu- 4 tion of the corporation after completion of the conference, the 5 person is entitled to a determination of the matter by the com- 6 missioner or his or her designee. 7 (4) By October 1, 1997, a health care corporation shall 8 establish, as part of its internal procedures, an expedited 9 grievance procedure. The expedited grievance procedure shall 10 provide that an initial determination will be made by the health 11 care corporation not later than 72 hours after receipt of the 12 grievance. Within 3 business days after the initial determina- 13 tion by the health care corporation, the member or a person, 14 including, but not limited to, a physician, authorized in writing 15 to act on behalf of the member may request further review by the 16 health care corporation or for a determination of the matter by 17 the commissioner or his or her designee under this section. If 18 further review is requested, a final determination by the health 19 care corporation shall be made not later than 30 days after 20 receipt of the request for further review. Within 10 days after 21 receipt of a final determination, the member or a person, includ- 22 ing, but not limited to, a physician, authorized in writing to 23 act on behalf of the member may request a determination of the 24 matter by the commissioner or his or her designee under this 25 section. If the initial or final determination by the health 26 care corporation is made orally, the health care corporation 27 shall provide a written confirmation of the determination to the 05140'97 4 1 member not later than 2 business days after the oral 2 determination. An expedited grievance under this subsection 3 applies if a grievance is submitted and a physician, orally or in 4 writing, substantiates that the time frame for a grievance under 5 subsections (1) to (3) would acutely jeopardize the life of the 6 member. This subsection does not apply to a provider's complaint 7 concerning claims payment, handling, or reimbursement for health 8 care services. As used in this subsection, "grievance" means an 9 oral or written statement, by a member or a person, including, 10 but not limited to, a physician, authorized in writing to act on 11 behalf of the member, to the health care corporation that the 12 health care corporation has wrongfully refused or failed to 13 respond in a timely manner to a request for benefits or payment. 14 (5) The commissioner shall by rule establish a procedure for 15 determination under this section, which shall be reasonably cal- 16 culated to resolve these matters informally and as rapidly as 17 possible, while protecting the interests of both the person and 18 the health care corporation. 19 (6) If either the health care corporation or the person dis- 20 agrees with a determination of the commissioner or his or her 21 designee under this section, the commissioner or his or her des- 22 ignee, if requested to do so by either party, shall proceed to 23 hear the matter as a contested case under the administrative pro- 24 cedures act. 05140'97 Final page. 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