1. Complaint System 28 TAC §10.22 Workers’ Compensation Health Care Networks

2. Complaint System Must Include: –Reasonable procedures for resolving oral and written complaints –Process for notice and appeal of complaint May use 90 day deadline for filing a complaint

3. Complaint System: Record of Complaints Complaint information must be saved for three years from the date the complaint was received Networks must keep complaint and appeal logs for each complaint

4. The Network shall maintain a complaint log regarding each complaint and categorize each complaint as one or more of the following: Quality of care or services Accessibility and availability of services or providers Utilization review and Retrospective review as applicable Complaint Procedures Health care provider contracts Bill payment, as applicable Fee disputes Miscellaneous

5. Complaints to The Department Who- Any person may submit a complaint The department's complaint form may be obtained at www.tdi.state.tx.us www.tdi.state.tx.us By mail to: Texas Department of Insurance, HWCN Division, Mail Code 103-6A, P. O. Box 149104, Austin, Texas 78714-9104 By facsimile (512) 490-1012 By e-mail HmoNewComplaints@tdi.state.tx.usHmoNewComplaints@tdi.state.tx.us or ConsumerProtection@tdi.state.tx.us ConsumerProtection@tdi.state.tx.us

6. Retaliatory Action A network may not engage in any retaliatory action against a provider, an employer or employee because the provider, employer or employee or a person acting on behalf of the employer or employee has filed a complaint against the network