(1) An insurer must have a written procedure, approved in writing by the department before implementation, for resolution of grievances or complaints brought by enrollees or their parents or guardians either individually or as a class. In a situation requiring urgent care or emergency care, the department may require the insurer to expedite resolution of a grievance within a time line established by the department.

(2) Except when CHIP eligibility has been denied, an enrollee, parent or guardian must exhaust the insurer's grievance procedure before appeal of the matter may be made to the department.

(3) An applicant, parent or guardian aggrieved by a denial, suspension or termination of CHIP eligibility or an enrollee, parent or guardian aggrieved by a final grievance decision of an insurer, including but not limited to a reduction or denial of benefits, may request a fair hearing in accordance with ARM 37.5.304, 37.5.313, 37.5.322, 37.5.325, 37.5.328, 37.5.334 and 37.5.337. The provisions of ARM 37.5.305 do not apply to such hearings.

(4) If a written request for hearing is not received by the department within 90 days after the date a notice of adverse action is mailed by the department or a final grievance decision is mailed by an insurer, the hearing officer may deny a hearing as provided in ARM 37.5.313.

(5) A proposal for decision by the hearing officer is a final agency decision for purposes of 2-4-702 , MCA and is subject to judicial review as provided in Title 2, chapter 4, part 7, MCA.