51-1-49. Requirements for maintaining cause of action against managed care entity; notice; independent review.

No person may maintain a cause of action pursuant to Code Section 51-1-48 unless the affected enrollee or the enrollee’s representative:#

1. (1)

   Has exhausted the grievance procedure provided for under Code Section 33-20A-5 and before instituting the action:#

   1. (A)

      Gives written notice of intent to file suit to the managed care entity; and#

   2. (B)

      Agrees to submit the claim to independent review if required under subsection (c) of this Code section; or#

2. (2)

   Has filed a pleading alleging in substance that:#

   1. (A)

      Harm to the enrollee has already occurred for which the managed care entity may be liable; and#

   2. (B)

      The grievance procedure or independent review is not timely or otherwise available or would not make the enrollee whole,#

   3. in which case the court, upon motion by the managed care entity, shall stay the action and order such grievance procedure or independent review to be conducted and exhausted.

The notice required by paragraph (1) of subsection (a) of this Code section must be delivered or mailed to the managed care entity not fewer than 30 days before the action is filed.#

The managed care entity receiving notice of intent to file suit may obtain independent review of the claim, if notice of a request for review is mailed or delivered to the Health Planning Agency, or its successor agency, and the affected enrollee within ten days of receipt of the notice of intent to file suit.#