Sec. 31.10.18.11. Demonstration of Compelling Reason to File Complaint

A. A member, a member’s representative, or a health care provider on behalf of a member may file a complaint without first exhausting the internal grievance process of a carrier if the complaint demonstrates to the satisfaction of the Commissioner a compelling reason to do so. A compelling reason includes showing that the potential delay in receipt of a health care service until after the member or health care provider exhausts the internal grievance process and obtains a final decision under the grievance process could result in:

(1) Loss of life;

(2) Serious impairment to a bodily function;

(3) Serious dysfunction of a bodily organ;

(4) The member remaining seriously mentally ill or using intoxicating substances with symptoms that cause the member to be in danger to self or others; or

(5) The member continuing to experience severe withdrawal symptoms.

B. A member is considered to be in danger to self or others if the member is unable to function in activities of daily living or care for self without imminent dangerous consequences.

C. In a case involving a retrospective denial, there is no compelling reason to allow a member, a member’s representative, or a health care provider on behalf of a member to file a complaint without first exhausting the internal grievance process of a carrier.