Section 2160.420  Appeals Process Responsibilities

The Member shall be responsible for handling appeals concerning claims payments.

a)         All correspondence concerning appeals must indicate the Unit in which the Member is enrolled in the Program.

b)         If a Member believes that an error has been made in the benefit amount allowed or disallowed, the Member should contact the claims processing office of the managed care plan or the Administrative Service Organization.  The member must utilize the Plan or the Administrator's review process to the fullest extent prior to contacting the Department.

c)         If the Member is not satisfied with the results of the review process by the managed care plan or Administrative Service Organization, the Member may submit a written request for review to the Department.

d)         If the Member is still not satisfied, the Member may appeal to the Advisory Board, which serves as the appeal committee. The Advisory Board will review the documentation and facts presented in the final determination and make a recommendation to the Director, whose decision shall be final and binding on all parties.  Notification of the decision will be made in writing.

(Source:  Amended at 25 Ill. Reg. 10306, effective August 3, 2001)