Grievance

RegQuest is pleased to announce its third module, focusing on grievance or administrative appeals.

As opposed to utilization management appeals that are based on a determination of medical necessity, grievance appeals pertain to the availability, delivery or quality of health care services, claims payment or reimbursement for health care services, or matters pertaining to the contractual relationship between a covered person and a health carrier. Depending on the state’s definition of grievance, these appeals may also include complaints regarding an adverse determination made pursuant to utilization review.

For many states, grievances are bygones from the era of HMOs and regulations in this area remain specifically pointed at the HMO system of care. RegQuest aims to provide a detailed overview of state grievance requirements and, where applicable, specifies if the regulatory scheme is specific to HMOs.

The information in this section focuses on several key components of these regulations including: information on the scope, regulatory contact information, licensure requirements, program requirements, reviewer qualifications, appeals process and other relevant information.