Library: Policy

317:2-3-4. Member grievances

Revised 7-1-23

(a) Filing.

(1) Filing with a CE or DBM. Except as described in this Section, when the member is enrolled in a managed care program, the member initially files a grievance with the CE or DBM in which the member is enrolled.

(2) Exception: Filing with OHCA. When the member is enrolled in a SoonerSelect program and the grievance deals with direct interaction with OHCA or its employees or officers, the member first files the grievance with OHCA as an administrative appeal pursuant to applicable rules set forth at OAC 317:2-1-2 et seq.

(b) Timing. A member may file a grievance, orally or in writing, at any time.

(c) Provider's and authorized representative's right to file a grievance. A provider or an authorized representative may file a grievance on behalf of a member, provided that the provider or authorized representative has obtained the member's written consent to do so. The authorized representative of a deceased member's estate may also be a party to the resolution of a grievance, as applicable.

(d) Clinical expertise in a grievance decision. When a grievance involves clinical issues or is related to a denial of an expedited resolution of an appeal, the decision maker(s) of such a grievance will have clinical expertise as discussed at OAC 317:2-3-6.

(e) Consideration of information in an appeal decision. The decision maker(s) for any appeal will take into account all comments, documents, records, and other information submitted without regard to whether such information was submitted or considered in the initial determination.

(f) OHCA-established timeframes for grievance decisions. A grievance related in any way to the member's health condition will be resolved, with notice provided, as expeditiously as the member's health condition requires.

(1) Per 42 C.F.R. § 438.408, the standard resolution of a grievance will occur within ninety (90) calendar days after the CE or DBM receives the grievance. The OHCA may choose to adopt a shorter timeframe for the grievance resolution. The CE and DBM must adhere to such timeframes that are described within the Contract.

(2) The CE and DBM may extend the timeframe up to fourteen (14) days if:

(A) The member requests the extension; or

(B) The CE and DBM shows (to the OHCA's satisfaction upon OHCA's request) that there is need for additional information and how the delay is in the member's interest.

(3) If the CE and DBM extends the timeframes not at the request of the member, it must complete all of the following:

(A) Make reasonable efforts to give the member prompt oral notice of the delay; and

(B) Within two (2) calendar days give the member written notice of the reason for the decision to extend the timeframe and inform Enrollee of the right to file a grievance if he or she disagrees with that decision; and

(4) The CE and DBM will adhere to all OHCA rules related to grievances, including but not limited to:

(A) Observing the timeframe for standard resolution of a grievance;

(B) Sending acknowledgement of receiving the grievance in writing to the member or the member's authorized representative within ten (10) calendar days of receipt; and

(C) Sending written notice conforming with this Subchapter to the affected parties within three (3) calendar days following resolution of the grievance.