TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.10 PURPOSE
Section 4520.10 Purpose
This Part will implement the
Managed Care Reform and Patient Rights Act [215 ILCS 134] in order to assure:
the proper provision of information to enrollees by health care plans; the
proper treatment of enrollees by health care plans; the proper treatment of
health care providers by health care plans; and the proper oversight of health
care plans by the Department of Insurance.
(Source:
Amended at 34 Ill. Reg. 6879, effective April 29, 2010)
 | TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.20 APPLICABILITY AND SCOPE
Section 4520.20 Applicability and Scope
The requirements of this Part are applicable to:
a) Policies
and contracts amended, delivered, issued, or renewed by health care plans
pursuant to the Act; and
b) The
program of health benefits under the State Employees Group Insurance Act, with
the exception of the fee for service program which only needs to comply with
Section 85 and the definition of "emergency medical condition"
contained in Section 10 of the Act; the Counties Code; the Illinois Municipal
Code; the Comprehensive Health Insurance Plan Act; the Health Maintenance
Organization Act; the Limited Health Service Organization Act, except for plans
offering only dental services, or only vision services; the Voluntary Health
Services Plans Act; and the medical assistance program and other programs
administered by the Department of Public Aid under the Illinois Public Aid Code,
except that complaints shall be handled consistent with the requirements of
Section 4520.80(a) of this Part; and
c) Third
party administrators, as defined in Article XXXI¼ of the Code, and entities
regulated under Article XX½ of the Code, generally referred to as Preferred
Provider Organizations (PPOs) must comply with the requirements of Section 4520.90
and Exhibit A of this Part pursuant to Section 55 of the Act; and
d) Any
person who conducts a utilization review program in this State, except that the
provisions of Section 85 of the Act are not applicable to bodily injury
liability claims (including uninsured motorist and underinsured motorist
coverage claims) arising under property and casualty contracts issued under
Class 2 and Class 3 of Section 4 of the Code [215 ILCS 5/4] and does not
include the retrospective review of a claim that is limited to an evaluation of
reimbursement levels, veracity of documentation, accuracy of coding or
adjudication for payment. Section 85 is also specifically applicable to third
party administrators, PPOs and insurance companies that transact the kinds of
insurance authorized under Class 1(b) or Class 2(a) of Section 4 of the Code.
For purposes of this Part, an entity shall be considered to be conducting a
utilization review program in this State if it evaluates the use of health care
services, procedures, and facilities by persons who are either covered under
contracts of insurance entered into in this State, or enrolled in an entity
licensed pursuant to the Health Maintenance Organization Act, the Limited
Health Service Organization Act or the Voluntary Health Services Plans Act; and
e) Preferred
provider administrators, as defined in Section 370g(g) of the Code, and
insurance companies that transact the kinds of insurance authorized under Class
1(b) or Class 2(a) of Section 4 of the Code must also comply with the
definition of the term emergency medical condition, as defined in Section 10 of
the Act.
(Source: Amended at 28 Ill. Reg. 13711,
effective September 28, 2004)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.30 DEFINITIONS
Section 4520.30 Definitions
"Act"
means the Managed Care Reform and Patient Rights Act [215 ILCS 134].
"Code"
means the Illinois Insurance Code [215 ILCS 5].
"Department"
means the Illinois Department of Insurance.
"Director"
means the Director of the Illinois Department of Insurance.
"Health
Care Plan" means a plan that establishes, operates, or maintains a network
of health care providers that has entered into an agreement with the plan to
provide health care services to enrollees to whom the plan has the ultimate
obligation to arrange for the provision of or payment for services through
organizational arrangements for ongoing quality assurance, utilization review
programs, or dispute resolution. Nothing in this definition shall be construed
to mean that an independent practice association or a physician hospital
organization that subcontracts with a health care plan is, for purposes of that
subcontract, a health care plan. For purposes of this definition, "health
care plan" shall not include the following:
indemnity
health insurance policies including those using a contracted provider network;
health care plans that offer only dental or only vision coverage;
preferred
provider administrators, as defined in Section 370g(g) of the Illinois
Insurance Code;
employee or
employer self-insured health benefit plans under the federal Employee
Retirement Income Security Act of 1974;
health care
provided pursuant to the Workers' Compensation Act or the Workers' Occupational
Diseases Act; and
not-for-profit
voluntary health services plans with health maintenance organization authority
in existence as of January 1, 1999 that are affiliated with a union and that
only extend coverage to union members and their dependents.
"Health
Care Provider" means any physician, hospital facility, nursing home or
other person that is licensed or otherwise authorized to deliver health care
services. Nothing in the Act shall be construed to define independent practice
associations or physician hospital organizations as health care providers.
"Long-Standing
Relationship" means the continuous relationship between an enrollee and
his or her primary care physician of not less than 5 years; except in the case
of a child 5 years or under who has had a continuous relationship with the same
primary care physician since birth, placement for adoption, guardianship or
foster care.
"Managed
Care Organization" or "MCO" means a partnership, association,
corporation or other legal entity, including but not limited to individual
practice associations (IPAs) and Physician Hospital Organizations (PHOs), which
delivers or arranges for the delivery of health care services through providers
it has contracted with or otherwise made arrangements with to furnish such
health care services.
"Nursing
Home" means a skilled nursing care facility that is subject to licensure
by the Illinois Department of Public Health under the Nursing Home Care Act
[210 ILCS 45].
"Ongoing
Course of Treatment" means the treatment of a condition or disease that
requires repeated health care services pursuant to a plan of treatment by a
physician because of the potential for changes in the therapeutic regimen.
"Person"
means a corporation, association, partnership, limited liability company, sole
proprietorship, or any other legal entity.
"Referral
Arrangement" means that, for each referral or standing referral, a
referral arrangement exists between a participating primary care physician and
a participating specialist physician or a participating health care provider
when a participating primary care physician makes a referral of an enrollee for
that referral or standing referral to a participating specialist physician or
participating health care provider.
"Standing
Referral" means a written referral from the primary care physician for an
ongoing course of treatment pursuant to a treatment plan specifying needed
services and time frames developed by a specialist in consultation with the
primary care physician and in accordance with procedures developed by the
health care plan.
"Utilization
Review" means the evaluation of the medical necessity, appropriateness,
and efficiency of the use of health care services, procedures, and facilities.
"Utilization
Review Organization" or "URO" means an entity that has
established one or more utilization review programs. This definition does not
include:
persons
providing utilization review program services only to the federal government;
self-insured
health plans under the Federal Employee Retirement Income Security Act of 1974
(ERISA); however, this Part does not apply to persons conducting a utilization
review program on behalf of these health plans;
hospitals and
medical groups performing utilization review activities for internal purposes;
however, this Part does apply when the hospital or medical group is conducting
utilization review for another person.
"Utilization
Review Program" means a program established by a person to perform
utilization review.
(Source: Amended at 43 Ill. Reg. 11479,
effective September 24, 2019)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.40 PROVISION OF INFORMATION
Section 4520.40 Provision of
Information
Description of Coverage
A written summary of benefits
and coverage (SBC) in accordance with 50 Ill. Adm. Code 2001.10, must be provided
to the enrollee by the health care plan.
(Source: Amended at 38 Ill.
Reg. 2253, effective January 2, 2014)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.50 NOTICE OF NONRENEWAL OR TERMINATION
Section 4520.50 Notice of
Nonrenewal or Termination
a) All provider agreements shall provide for at least 60 days
notice by the provider for termination with cause, as defined in the provider
agreement, and at least 90 days notice by the provider for termination without
cause. Upon receipt of the notice, the health care plan shall notify enrollees
within 30 days after the termination and the proper steps to be taken for
selecting a new health care provider. In the event the provider violates the
provider agreement and does not give a notice of termination in the appropriate
timeframe, the health care plan must provide immediate notice to the
enrollees. The health care plan must inform the Department immediately of any
known or intended termination, with or without cause, of an MCO.
b) A health care plan must give at least 60 days notice of
nonrenewal or termination of a health care provider to the health care provider
and to the enrollees served by the health care provider. The notice shall
include a name and address to which an enrollee or health care provider may
direct comments and concerns regarding the nonrenewal or termination.
Immediate written notice may be provided without 60 days notice when a health
care provider's license has been disciplined by a State licensing board. The
notice shall inform the enrollee of the availability of transitional services
and that the enrollee must request transitional services within 30 days from
receipt of this notice.
(Source: Amended at 38 Ill.
Reg. 2253, effective January 2, 2014)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.60 TRANSITION OF SERVICES
Section 4520.60 Transition
of Services
a) Health care plans shall notify new enrollees and current
enrollees of the availability of transitional services for conditions that
require ongoing course of treatment.
b) New enrollees must request the option of transitional services
in writing, within 15 days after receiving notification of the availability of
transitional services, through a mechanism established by the health care plan.
c) Enrollees whose physician leaves the health care plan's
network of health care providers shall request the option of transitional
services in writing within 30 days after receipt of notification of termination
of the physician.
d) Within 15 days after receiving such notification from the
enrollee, the health care plan shall notify the enrollee if a denial is issued
for the enrollee's request of transitional services based on the enrollee's
physician refusing to agree to accept the health care plan's reimbursement
rates, adhere to the health care plan's quality assurance requirements, provide
the health care plan with necessary medical information related to the
enrollee's care, or otherwise adhere to the health care plan's policies and
procedures. The notification shall be in writing and include the specific
reason for such denial.
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.70 HEALTH CARE SERVICES, APPEALS, COMPLAINTS AND EXTERNAL INDEPENDENT REVIEWS
Section 4520.70 Health Care Services, Appeals,
Complaints and External Independent Reviews
a) A
plan shall implement an effective appeals process for appeals of coverage
determinations and claims, under which the health care plan shall, at a minimum:
1) have
in effect an internal claims appeal process;
2) provide
notice to enrollees, in a culturally and linguistically appropriate manner,
of available internal and external appeals processes, and the availability of
Department consumer assistance to assist enrollees with the appeals processes;
and
3) allow
an enrollee to review his or her file, to present evidence and testimony as
part of the appeals process, and to receive continued coverage pending the
outcome of the appeals process. (Section 2719 of the Public Health Service Act;
42 USC 201 et seq.)
b) A
plan shall affirm or deny liability on claims within a reasonable time and
shall offer payment within 30 days after affirmation of liability, if the
amount of the claim is determined and not in dispute. For those portions of
the claim that are not in dispute and the payee is known, the plan shall tender
payment within the 30 days.
c) If a
settlement of a claim is less than the amount claimed, or if the claim is
denied, the plan shall provide to the insured a reasonable written explanation
of the basis of the lower offer or denial within 30 days after the
investigation and determination of liability is completed. This explanation
shall clearly set forth the policy definition, limitation, exclusion or
condition upon which denial was based. The explanation shall clearly inform
the enrollee of the right to appeal the claim reduction or denial, the process
by which the enrollee (or the enrollee's designee or guardian) may initiate the
appeal process and the plan's phone number to call to receive more information
concerning the appeal process. Notice of Availability of the Department shall
accompany this explanation.
d) A
health plan shall ensure that an enrollee (or the enrollee's designee or
guardian) has a period of not less than 180 days after the date of the
explanation of a denial of a claim for benefits in which to appeal the denial
under this Section. The only exception to this requirement is those complaints
that are handled by the Department of Healthcare and Family Services (HFS),
consistent with the requirements of Section 4520.80(a).
(Source: Amended at 38 Ill.
Reg. 2253, effective January 2, 2014)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.80 JOINT RESOLUTION OF COMPLAINTS DEPARTMENT OF INSURANCE AND DEPARTMENT OF PUBLIC HEALTH - NOTIFICATION AND RESOLUTION PROCESS
Section 4520.80 Joint
Resolution of Complaints – Department of Insurance and Department of Public
Health − Notification and Resolution Process
a) Complaints against health care plans participating in programs
administered by the Department of Healthcare and Family Services (HFS) pursuant
to the Public Aid Code shall be resolved under rules published by HFS. Any
complaints against such plans received by the Department of Insurance or the
Department of Public Health shall be referred to HFS.
b) Any enrollee or health care provider, on behalf of the
enrollee, may file a written complaint against the health care plan through the
Department of Insurance. Complaints received by the Department of Public
Health shall be referred to the Department of Insurance for processing prior to
investigation.
c) The health care plan response shall include documentation and
an explanation of all actions taken or not taken that were the basis for the
complaint. The respondent shall include documents necessary to support the
respondent's position and any additional information requested by the
Department of Insurance and/or the Department of Public Health. Both the Department
of Insurance and the Department of Public Health shall maintain confidentiality
of medical records and other pertinent documents.
d) Quality of care complaints may be referred to the Department
of Public Health for investigation.
1) The Department of Public Health shall determine if an on-site
investigation is warranted and may request additional information from the
complainant, health care provider, or health care plan if the information
provided is determined to be incomplete or if additional information is needed
to make a determination regarding the complaint.
2) If an investigation is warranted, the Department of Public
Health shall make available the name, address and telephone number where an
enrollee may obtain the status of the complaint.
3) The Department of Public Health shall forward the findings of
the investigation to the Department for final disposition and record keeping.
e) No Department of Insurance or Department of Public Health
publication or release of information shall identify any enrollee, health care
provider, or individual complainant.
(Source:
Amended at 34 Ill. Reg. 6879, effective April 29, 2010)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.90 RECORD OF COMPLAINTS
Section 4520.90 Record of
Complaints
a) Complaint, as used in this Section, means any communication
primarily expressing a grievance to the health care plan by, or on behalf of,
the enrollee, or by the health care provider. For purposes of this definition,
"communication" shall include the following:
1) A written notice relating to the health care plan's
determinations, procedures and administration as stated in Sections 45 and 50
of the Act; and
2) Written or oral notice filed under the expedited health care
services appeal process or under the utilization review process.
b) The health care plan shall submit to the Director a report by
April 1 for the previous calendar year that shall include a record of the
plan's complaints in the format prescribed in Exhibit A. Beginning April 1, 2005,
all plans or companies must electronically submit the record of complaints to
the Director in a format prescribed by the Director.
c) Any plan or company failing to file a complaint report by
April 1 for the previous calendar year may be subject to a late fee of $100 for
each day the report is late.
(Source: Amended at 38 Ill.
Reg. 2253, effective January 2, 2014)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.100 ACCESS AND QUALITY OF CARE FROM PROVIDERS WITHOUT PRIMARY CARE PHYSICIAN REFERRAL OR AUTHORIZATION
Section 4520.100 Access and
Quality of Care from Providers Without Primary Care Physician Referral or
Authorization
a) Health care plans that allow enrollees to access health care
services from contractual providers without a referral or authorization from
the primary care physician (PCP) shall have in place a system for centralized
record keeping to track and monitor the provider/enrollee encounters to assure
that enrollees are receiving needed services.
b) The health care plan's centralized record keeping system for
access and quality of care shall be described in detail, filed with and deemed
acceptable by the Director of Public Health. The Director of Public Health
shall forward a copy of the approved system for record keeping and the notice
of his or her final action with the Department of Insurance.
c) The health care plan shall be able to retrieve an enrollee's centralized
record of the provider/enrollee encounters for review by the Department and/or
Department of Public Health as part of a complaint investigation or inquiry.
(Source: Amended at 34 Ill. Reg. 6879, effective April 29, 2010)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.110 EMERGENCY SERVICES
Section 4520.110 Emergency
Services
a) For purposes of determining compliance with Section 65 of the
Act, timely determination shall mean a determination is made within 30 days
after the health care plan receives a claim for emergency services if no
additional information is needed to determine the emergency services meet the
definition of an emergency medical condition. In the event additional
information is necessary to make the determination, the health care plan shall
request the medical record documenting the presenting symptoms at the time care
was sought within 15 days after receipt of the emergency services claim and
make a determination within 30 days after its receipt.
b) If
a group health care plan offering group or individual health insurance,
provides or covers any benefits with respect to services in an emergency
department of a hospital, the plan shall cover emergency services in a manner
that those services will be provided without imposing a requirement under the
plan for prior authorization of services or any limitation on coverage when the
provider of services does not have a contractual relationship with the plan for
the providing of services that is more restrictive than the requirements or
limitations that apply to emergency department services received from providers
who do have such a contractual relationship with the plan.
c) In addition to complying with the coverage requirements
provided in 50 Ill. Adm. Code 2051.310(a)(6)(J), if emergency services are
provided out-of-network, the cost-sharing requirement (expressed as a copayment
amount or coinsurance rate) is the same requirement that would apply if the
services were provided in-network. (Section 2719A(b) and (c)(ii) of the Public
Health Service Act (42 USC 300 gg-19(1)))
(Source: Amended at 38 Ill.
Reg. 2253, effective January 2, 2014)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.120 POST STABILIZATION SERVICES
Section 4520.120 Post
Stabilization Services
For purposes of determining
compliance with Section 70 of the Act, timely determination shall mean a
determination is made within 30 days after the health care plan receives a
claim for post stabilization services if no additional information is needed to
determine that services rendered were not contrary to the instructions of the
health care plan or its delegated health care provider if the contact was made
between those parties and the treating health care provider prior to the
services being rendered. In the event additional information is necessary to
make such a determination, the health care plan shall request the medical
record documenting the time, phone number dialed, and the result of the
communication for request for authorization of post stabilization medical
services as well as the post stabilization medical services rendered within 15
days after receipt of the post stabilization services claim and make a
determination within 30 days after its receipt.
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.130 REGISTRATION OF UTILIZATION REVIEW ORGANIZATIONS
Section 4520.130
Registration of Utilization Review Organizations
a) Registration: On or after July 1, 2000, a URO may not conduct
utilization review for persons subject to Section 85 of the Act unless the URO
has registered with the Director. An application for registration shall be made
using the standard form available on the Department website (https://insurance.illinois.gov),
and must be signed by an officer or director of the URO. Initial registration
applications shall be deemed approved unless the Director finds the application
to be noncompliant with either the standards set forth in Section 85 of the Act
or this Part.
b) The application for registration shall include, but not be limited
to, the following information: applicant's identifying and contact information;
applicant's agent for service of process in Illinois; applicant's accreditation
status; signed affirmation by an officer or director; and for each utilization
review program: contact information and business hours; organization and
governing structure; number of reviews in Illinois for the current and previous
years; description of the grievance process; written policies and procedures
for protection of confidential information; and biographical information for
officers and directors. The Department will accept the biographical affidavit,
and any supplement to that affidavit, that is obtained from the website of the
National Association of Insurance Commissioners (NAIC) or the Department.
c) Fees: A URO must register with the Director every two years.
A fee of $3,000 must be submitted with each application or renewal unless the URO
is accredited by URAC (formerly Utilization Review Accreditation Commission),
the National Committee for Quality Assurance (NCQA), The Joint Commission
(JCAHO), or the Accreditation Association for Ambulatory Health Care (AAAHC),
in which case the fee is $1500.
d) Any material changes in the information filed pursuant to this
Part shall be filed with the Director within 30 days after the change. Loss of
accreditation status will require re-registration and payment of a $3000 fee
pursuant to subsections (a) and (b).
e) Renewals and Appeals:
1) A registered URO may continue to operate, if the application
and fee have been filed 30 days prior to the renewal date, until the renewal is
denied or issued by the Director.
2) If the renewal application and fee are not received prior to
the renewal date, the registration will automatically expire and the URO must
re-register and pay a fee pursuant to subsections (a) and (b).
3) If an application for registration or renewal is denied under
this Part, the applicant may appeal that denial by requesting a hearing under
Article 10 of the Illinois Administrative Procedure Act [5 ILCS 100] and 50
Ill. Adm. Code 2402. A petition for hearing must be postmarked no later than 30
days after the date of initial denial. A hearing shall be scheduled within 45
days after the petition is filed with the Director. A decision by the Director
shall be rendered within 60 days after the close of the hearing.
(Source: Amended at 46 Ill. Reg. 9881, effective May 31, 2022)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.140 OPERATIONAL REQUIREMENTS
Section 4520.140 Operational
Requirements
A URO shall comply with all URAC
standards except when specifically addressed by Sections 45 and 50 of the Act
for health care plans. The terms in Sections 45 and 50 of the Act shall have
the meaning assigned by the Act. Utilization review decisions shall be issued
pursuant to the Managed Care Reform and Patient Rights Act [215 ILCS 134].
(Source: Amended at 43 Ill. Reg. 11479, effective September 24, 2019)
Section 4520.EXHIBIT A Complaint Record and Column Descriptions
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.EXHIBIT A COMPLAINT RECORD AND COLUMN DESCRIPTIONS
Section 4520.EXHIBIT A Complaint
Record and Column Descriptions
1. Column A. Health Care Plan Identification Number – This is
the identification number used by the health care plan to identify the
complaint internally. The identification number must be unique for each
complaint.
2. Column B. Complaint Origin – complaint was filed by:
a) Consumer or enrollee;
b) Provider;
c) Any other individual.
3. Column C. Function Code. Complaints are to be classified by functions
or the health care plan involved, as follows:
a) Denial of care or treatment (dissatisfaction regarding
prospective non-authorization of a request for care or treatment recommended by
a provider excluding diagnostic procedures and referral requests; partial
approvals and care terminations are also considered to be denials);
b) Denial of diagnostic procedure (dissatisfaction regarding
prospective non-authorization of a request for a diagnostic procedure
recommended by a provider; partial approvals are also considered to be
denials);
c) Denial of referral request (dissatisfaction regarding
non-authorization of a request for a referral to another provider recommended
by a PCP);
d) Sufficient choice and accessibility of health care providers (dissatisfaction
by an enrollee or policyholder regarding the extent to which the health care
plan has practitioners/providers of the appropriate type and number distributed
geographically to meet the needs of the member; in addition, dissatisfaction
by an enrollee or policyholder regarding the extent to which the enrollee or
policyholder may obtain available services at the time they are needed − available
service refers to both telephone access and ease of scheduling an appointment);
e) Underwriting (dissatisfaction by an enrollee or policyholder
regarding the health care plan's process of examining, accepting, or rejecting
insurance risks and classifying those selected in order to charge the proper
premiums for each);
f) Marketing and sales (dissatisfaction regarding solicitation or
the sale of a policy by the managed care organization; solicitation means any
method by which information relative to the health care plan is made known to
the public for the purpose of informing or influencing potential enrollees to
enroll in the health care plan, regardless of the media or technique used);
g) Claims and utilization review (dissatisfaction regarding the
concurrent or retrospective evaluation of the coverage, medical necessity,
efficiency or appropriateness of health care services or treatment plans; prospective
"Denials of care or treatment," "Denials of diagnostic
procedures" and "Denials of referral requests" should not be
classified in this category, but the appropriate one above);
h) Member services (dissatisfaction by an enrollee or
policyholder related to response time regarding provision of information;
handling of a complaint, appeal or external review; or any interaction between
plan representatives and enrollee);
i) Provider relations:
I) Quality
of Care (dissatisfaction regarding any aspect of care provider by an
institution or organization or practitioner that provides services to a managed
care organization's members; this category does not include sufficient choice
or accessibility of a provider);
II) Provider
complaints − Prompt Pay (complaints by providers (prompt pay, etc.),
excluding those filed under "Denials of care or treatment," "Denials
of diagnostic procedures" and "Denials of referral request"
above);
j) Miscellaneous (any "complaint", as defined above,
not falling in one of the above categories).
4. Column D. Date Received – date received by the
health care plan.
5. Column E. Date Closed – date closed by the health care plan.
6. Column F. Illinois Department of Insurance Complaint File
Number – If the complaint was also sent to the health care plan from the Department,
the health care plan should provide the IDOI complaint number in this column.
7. Column G. Illinois Department of Insurance Complaint File
Closed Date. The Department will provide the company with the date the
complaint was closed by the Department.
8. Column H. External Review – indicate by placing an
"X" in the column if complaint was processed through external review
procedure.
9. Column I. Disposition.
a) Relief Granted −
If the complaint was resolved in favor of the complainant;
b) Partial
Relief Granted − If the complaint was only partially resolved in favor of
the complainant;
c) Information
Furnished − The complaint did not require action, only information to be
provided to the enrollee;
d) No
Relief Granted − If the complaint was not resolved in favor of the
complainant.
(Source: Amended at 38 Ill.
Reg. 2253, effective January 2, 2014)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.EXHIBIT B APPLICATION FOR REGISTRATION OF A UTILIZATION REVIEW ORGANIZATION (REPEALED)
Section 4520.EXHIBIT B Application
for Registration of a Utilization Review Organization (Repealed)
(Source: Repealed at 46 Ill.
Reg. 9881, effective May 31, 2022)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.EXHIBIT C UTILIZATION REVIEW ORGANIZATION OFFICERS AND DIRECTORS BIOGRAPHICAL AFFIDAVIT (REPEALED)
Section 4520.EXHIBIT C Utilization
Review Organization Officers and Directors Biographical Affidavit (Repealed)
(Source: Repealed at 43 Ill. Reg. 11479, effective September 24, 2019)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4520
MANAGED CARE REFORM & PATIENT RIGHTS
SECTION 4520.EXHIBIT D NAIC UTILIZATION REVIEW ORGANIZATION OFFICERS AND DIRECTORS BIOGRAPHICAL AFFIDAVIT (REPEALED)
Section 4520.EXHIBIT D NAIC Utilization Review
Organization Officers and Directors Biographical Affidavit (Repealed)
(Source: Repealed at 43 Ill. Reg. 11479,
effective September 24, 2019)
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