<?xml version='1.0' encoding='utf-8'?>
<section article="ghg" article_name="Health - General" number="19-705.2" title_number="19" title_name="Health Care Facilities" subtitle_number="7" subtitle_name="Health Maintenance Organizations">
  <level label="a">
    <text>With the advice of the Secretary, the Commissioner shall adopt regulations to establish a system for the receipt and timely investigation of complaints of members and subscribers of health maintenance organizations concerning the operation of any health maintenance organization in this State.</text>
  </level>
  <level label="b">
    <text>The complaint system shall include:</text>
    <level label="1">
      <text>A procedure for the timely acknowledgment of receipt of a complaint;</text>
    </level>
    <level label="2">
      <text>Criteria that the Secretary shall adopt by regulation for determining the appropriate level of investigation for a complaint concerning quality of care, including:</text>
      <level label="i">
        <text>A determination as to whether the member or subscriber with the complaint previously attempted to have the complaint resolved; and</text>
      </level>
      <level label="ii">
        <text>A determination as to whether a complaint should be sent to the member’s or subscriber’s health maintenance organization for resolution prior to investigation under the provisions of this section; and</text>
      </level>
    </level>
    <level label="3">
      <text>A procedure for the referral of quality of care complaints to the Secretary for an appropriate investigation.</text>
    </level>
  </level>
  <level label="c">
    <text>If a determination is made to investigate a complaint under the provisions of this section prior to the member or subscriber attempting to otherwise resolve the complaint, the reasons for that determination shall be documented.</text>
  </level>
  <level label="d">
    <text>Notice of the complaint system established under the provisions of this section shall be included in all contracts between a health maintenance organization and a member or subscriber of a health maintenance organization.</text>
  </level>
  <level label="e">
    <text>For quality of care complaints referred to the Secretary for investigation under subsection (b)(3) of this section, the Secretary shall report to the Commissioner in a timely manner on the results and findings of each investigation.</text>
  </level>
</section>
