Ill. Admin. Code tit. 50, § 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.
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