Ill. Admin. Code tit. 50, § 4520.80 - Joint Resolution of Complaints - Department of Insurance and Department of Public Health - Notification and Resolution Process
Current through Register Vol. 46, No. 15, April 8, 2022
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.
Notes
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