(215 ILCS 134/50)

Sec. 50. Administrative complaints and Departmental review.

(a) Administrative complaint process.

(1) A health care plan shall accept and review appeals of its determinations and complaints related to administrative issues initiated by enrollees or their health care providers (complainant). All appeals of a health care plan's determinations and complaints related to health care services shall be handled as required under Section 45. Nothing in this Act shall be construed to preclude an enrollee from filing a complaint with the Department or as limiting the Department's ability to investigate complaints. In addition, any enrollee not satisfied with the plan's resolution of any complaint may appeal that final plan decision to the Department.

(2) When a complaint against a health care plan (respondent) is received by the Department, the respondent shall be notified of the complaint. The Department shall, in its notification, specify the date when a report is to be received from the respondent, which shall be no later than 21 days after notification is sent to the respondent. A failure to reply by the date specified may be followed by a collect telephone call or collect telegram. Repeated instances of failing to reply by the date specified may result in further regulatory action.

(3) The respondent's report shall supply adequate documentation that explains all actions taken or not taken and that were the basis for the complaint. The report shall include documents necessary to support the respondent's position and any information requested by the Department. The respondent's reply shall be in duplicate, but duplicate copies of supporting documents shall not be required. The respondent's reply shall include the name, telephone number, and address of the individual assigned to investigate or process the complaint. The Department shall respect the confidentiality of medical reports and other documents that by law are confidential. Any other information furnished by a respondent shall be marked "confidential" if the respondent does not wish it to be released to the complainant.

(b) Departmental review. The Department shall review the plan decision to determine whether it is consistent with the plan and Illinois law and rules. Upon receipt of the respondent's report, the Department shall evaluate the material submitted and:

(1) advise the complainant of the action taken and disposition of the complaint;

(2) pursue further investigation with the respondent or complainant; or

(3) refer the investigation report to the appropriate branch within the Department for further regulatory action.

(c) The Department of Insurance and the Department of Public Health shall coordinate the complaint review and investigation process. The Department of Insurance and the Department of Public Health shall jointly establish rules under the Illinois Administrative Procedure Act implementing this complaint process.

(Source: P.A. 91-617, eff. 1-1-00.)