Complaint and Grievance Procedures in Health Insurance Checklist

Provide guidance on the process for handling complaints and grievances filed by individuals who are covered under commercial health insurance policies. Better understand your client's obligations in the context of complaints and grievances, the structure of the complaint and grievance review process, and how to conduct legal research on the topic.

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Related Content

• Claims Processing in Health Insurance
  Get up to speed on claims processing for commercial health insurance plans in both individual and group contexts. Review the fundamental elements of claims processing for medical and hospital claims. Answer questions like, how to define a claim, how to prepare a claims timeline, what claims forms to use, and how to research applicable law such as the Patient Protection and Affordable Care Act (ACA), the Employee Retirement Income Security Act (ERISA), and National Association of Insurance Commissioners (NAIC) model laws and regulations that govern claims processing.
• Claims Procedure ERISA Requirements Checklist (Group Health Plans)
  Benefit from these checklists, which describe the enhanced standards for a group health plan's benefit claims procedure under ERISA and the ACA. Stay compliant with these laws, which generally require plans to establish and maintain a process reasonably designed to ensure a full and fair review of benefit claims and claimant appeals of adverse determinations.
• Mandatory Provisions in Health Insurance Policies State Law Survey
  Identify provisions that must be included in health insurance policies to comply with the law of the jurisdiction in which the policy is delivered and applicable federal law. Review the laws and regulations in all 50 U.S. states, the District of Columbia, Guam, and Puerto Rico. Understand how states have attempted to regulate both solvency (claims-paying ability) and the skill, licensing, honesty, discipline, and ongoing education of insurance operatives.

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