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What happens if a complaint is filed against an HMO?

If a complaint is filed against an HMO, the Department will send an opening letter along with a copy of the complaint to the HMO. The HMO must provide a written response no later than the date provided in TDI's request.

Once the Department receives the response from the HMO the Department will review the response to see if the response has complied with the Department's rules and regulations. Based on the Departments review of the HMO's response, additional documentation may be requested.

The HMO's response should include:

  • Type of health plan coverage (HMO, Group, Individual, Medicare Risk, Small Employer Group, Point of Service "Wrap," Self-funded ERISA, ERS, COBRA, Federal, or other)
  • Branch office serving this member policy
  • Form Filing Number for EOC and date of approval
  • Describe whether or not the provider is contracted
  • Describe whether or not the claim is a clean claim and if not, the reason it is not a clean claim
  • Describe whether the provider's contract became effective or was renewed on or after 8/16/03, and if so, the date the contract became effective or was renewed
  • A copy of customer service screens
  • A copy of referral requests, if applicable
  • Correspondence exchanged between plan and member and/or plan and provider, including but not limited to, screen printouts of telephone conversations, internal memos
  • Evidence of claim adjudication
  • A statement, in chronological order, of all actions taken regarding this case
  • Any other documentation the Department deems necessary to review the complaint

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Last updated: 2/27/2017