Texas General Lines — Life, Accident, Health and HMOTexas Statutes and Rules Common to Life, Accident, Health and HMOMedium
A Health Maintenance Organization (HMO) operating in Texas is required to establish and maintain a complaint system. Which of the following is NOT a mandatory component of an HMO's complaint system, according to Texas regulations?
- AA requirement for all complaints to be submitted via certified mail.
- BProcedures for prompt investigation and resolution of complaints.
- CA designated complaint officer to oversee the system.
- DA written record of each complaint.
Show answer & explanationAnswer & explanation
Correct answer: A. A requirement for all complaints to be submitted via certified mail.
Texas regulations require HMOs to have a complaint system that includes written records, a designated complaint officer, and prompt investigation procedures. There is no requirement for complaints to be submitted only via certified mail, as this would unduly restrict access.
Why the other options are wrong
- B. Procedures for prompt investigation and resolution are mandatory for effective complaint handling.
- C. Designating a complaint officer is a mandatory component for oversight.
- D. Maintaining written records is a mandatory component for accountability.
HMO Complaint System
Texas law requires Health Maintenance Organizations (HMOs) to establish a formal system for receiving, investigating, and resolving enrollee complaints.
- Must include written records of complaints.
- Requires a designated complaint officer.
- Must have procedures for prompt investigation and resolution.
Memory trick: HMO's complaint system: Record, Officer, Resolve, but no 'certified mail only' rule.