New York State Seal

STATE OF NEW YORK
INSURANCE DEPARTMENT

AGENCY BUILDING ONE
EMPIRE STATE PLAZA
ALBANY, NY 12257

 

Circular Letter No. 5 (1999)
February 19, 1999

 

TO: ALL INSURERS LICENSED TO WRITE ACCIDENT & HEALTH INSURANCE IN NEW YORK STATE, ARTICLE 43 CORPORATIONS AND HEALTH MAINTENANCE ORGANIZATIONS
RE: MANAGED CARE GRIEVANCE AND UTILIZATION REVIEW APPEAL DATA

This circular letter will provide guidance to insurers and health maintenance organizations (HMOs) about how grievance and utilization review (UR) appeals should be reported to the Insurance Department. The purpose of this circular letter is to facilitate the consistent reporting of information among HMOs and insurers for inclusion in the Department’s Annual Consumer Guide, which will be published in September 1999. This circular letter is not intended to impose additional requirements on the grievance procedures or utilization review processes that are already in place.

Section 210(b)(1) of the New York State Insurance Law mandates that HMOs and insurers report to the Insurance Department the number of grievances filed pursuant to  4408-a of the Public Health Law (as added by Chapter 705 of the Laws of 1996) or Section 4802 of the Insurance Law, and the number of such grievances where a determination was reversed in whole or in part compared to the number of determinations that were upheld. Section 210(b)(2) of the Insurance Law also requires HMOs and insurers to report the number of appeals to UR determinations which were filed pursuant to Article 49 of the Public Health Law or Article 49 of the Insurance Law and the number of adverse determinations which were reversed versus the number upheld. HMOs and insurers must include grievance and UR appeal information in the annual statements they are required to file with the Insurance Department.

The following will address the issues that were raised by insurers and HMOs when filing grievance and UR appeal data with the Insurance Department:

What is a Grievance?

Insurers and HMOs, for purposes of reporting information in their respective annual statements, should only report the number of grievance determinations that have been subject to the formal grievance procedure. In 1998, the Department found that some plans included the number of all complaints in their annual statements, regardless of whether the complaint related to a determination or was subject to the formal grievance procedure. Insurers and HMOs should not include complaints that are not related to a plan determination or that are not subject to the formal grievance procedure when reporting information in their annual statements. In addition, oral complaints that are not acknowledged in writing, or otherwise subject to the formal grievance procedure, should not be reported in the annual statement.

Which Entities Should Report Grievance Information?

*Those insurers that have voluntarily implemented a grievance procedure not subject to the provisions of Chapter 705 of the Laws of 1996 are encouraged to report grievance information; be certain, however, to note that such information comes from a voluntary program. 

Number of Grievances Filed:

When Should a Grievance be Considered Closed?

If the subscriber appeals the first level grievance determination in a subsequent calendar year, and the appeal is considered timely by the insurer or HMO, the insurer or HMO should report the grievance appeal determination in the annual statement as either a grievance closed resulting in a reversal or as a grievance that was upheld. Insurers and HMOs should not count the grievance appeal in the number of grievances filed column in the annual statement for that subsequent year.

Point of Service Contracts:

What is a Utilization Review Appeal?

UR Appeals Subject to Expedited and Standard Review:

When a UR Appeal Should be Considered Closed:

If the subscriber appeals the expedited determination in a subsequent calendar year, and the appeal is considered timely by the insurer or HMO, the insurer or HMO should report the appeal determination in the annual statement as either an appeal closed resulting in a reversal or as an appeal closed in which the plan determination was upheld. Insurers and HMOs should not count the appeal in the number of appeals filed column of the annual statement for that subsequent year.

Utilization Review Agents:

Point of Service Contracts:

Sale of Business, Assumption or Merger:

Medicare:

Medicaid:

 

Any questions concerning this circular letter should be directed to:

Edmund B. Bellinger
Program Research Specialist 3, Health Bureau
New York State Insurance Department
25 Beaver Street
New York, NY 10004
(212) 480-5242

Thomas C. Zyra
Acting Chief, Health Bureau-Albany Office