Company Complaint Record

The Managed Care Reform and Patient Rights Act (P.A. 91-617) requires health care plans (HMOs) to provide the Division of Insurance with information on their closed complaints for the previous calendar year. Following is the information submitted for complaints closed by health care plans in calendar year 2001, including the resolution of those complaints.

A "complaint" is defined as:

any communication primarily expressing a grievance to the health care plan by, or on behalf of, the enrollee, or by the health care provider. For purposes of this definition, "communications" shall include the following: 1) a written notice relating to the health care plan's determinations, procedures and administration as stated in Sections 45 and 50 of the Act; and 2) written or oral notice filed under the expedited health care services appeal process or under the utilization review process."

Because this report is based entirely on the internal complaint records as determined by each company, no direct correlation necessarily exists between this complaint data and data reported by the Department in its annual release of complaint ratio information.

External Independent Review Record

The Managed Care Reform and Patient Rights Act requires health care plans (HMOs) to allow enrollees to access an external independent review when they have received a final determination by the HMO that a health care service, treatment, procedure or referral is not medically necessary and therefore will not be paid for by the HMO.

The linked report was derived from the Company Complaint Record.

Because this report is based entirely on the internal complaint records for each company, no direct correlation necessarily exists between this complaint data and data reported by the Department in its annual release of complaint ratio information.