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)