Illinois Administrative Code › Title 50 - INSURANCE › Part 2051 - PREFERRED PROVIDER PROGRAMS › Section 2051.260 - Administrator Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
Each applicant for registration shall file the following
				information and documents with the Director in the format provided in the
				Health Care Preferred Provider Program Administrator Checklist. DHCSP
				administrators who only administer DHCSPs shall instead file in the format
				provided in the Discounted Health Care Services Plan Only Registration
				Checklist. WC PPP administrators shall instead file in the format provided in
				the Workers' Compensation Preferred Provider Program Administrator Registration
				Checklist. All of these checklists are located under "Managed Care
				License/Registration Information" on the Department's website at
http://insurance.illinois.gov/company/companyMain.html
.
a) Organizational requirements identified in
			 Section
			 2051.270;
b) Sample copies of all payor and provider
			 agreements identified in Sections
			 2051.280
			 and
			 2051.290,
			 when applicable. If the terms and conditions in an agreement include
			 significant, substantial or material change or additions, the filing of one
			 complete sample of each type of agreement, together with a description of all
			 variable terms and conditions, will satisfy this requirement;
c) Signed copies of all current
			 administrative agreements with any entity with which the applicant contracts to
			 provide services or to meet the requirements of the Act. Examples of these
			 contracts may include, but are not necessarily limited to, agreements with
			 other administrators, utilization review organizations, third party
			 administrators, third party prescription program administrators, risk-bearing
			 entities, and employers or employer groups for the purposes of WC PPPs.
			 Agreements at a minimum shall contain the following provisions:
1) Network availability and adequacy
			 requirements identified in Section
			 2051.310
			 or
			 2051.315;
2) If applicable, any DHCSP beneficiary
			 agreement requirements identified in Section
			 2051.320;
3) Copies of the preferred provider program
			 disclosure statements required to be furnished to beneficiaries by Section 370m
			 of the Act and illustrative advertising material to be used by the
			 applicant;
4) A description of
			 programs for utilization review, including procedures for timely investigation,
			 resolution of questions concerning medical necessity and appropriateness of
			 medical services and supplies and appeals from beneficiaries and providers as
			 provided by Section 370s of the Act and Section 85 of the Managed Care Reform
			 and Patient Rights Act [
			 215 ILCS
			 134/85 ] or, for the purposes of WC PPP, Section 8.7
			 of the Workers' Compensation Act. Administrators who administer only DHCSPs
			 need not comply with this subsection;
5) A description of any fiduciary account
			 established by the administrator, including the location and identification
			 number of the account, established and maintained pursuant to Section 370l of
			 the Act and Section
			 2051.340
			 of this Part; and/or a bond in compliance with Section 370l of the Act and
			 Section
			 2051.340
			 of this Part. If a bond is submitted, the administrator shall also furnish a
			 certification of the total estimated annual reimbursements under the preferred
			 provider program, supported by the methodology used to arrive at that
			 figure;
6) Administrators may not
			 participate in an exclusive provider organization in this State, except when
			 such an arrangement is shown to be in the best interest of the beneficiaries
			 and has been expressly approved by the Director in writing. This subsection
			 (c)(6) does not apply to administrators offering only DHCSPs.
7) WC PPP administrators that utilize
			 economic evaluation of their providers shall file a description of any policies
			 and procedures related to the economic evaluation utilized by the program. The
			 filing shall describe how these policies and procedures are used in utilization
			 review, peer review, incentive and penalty programs, and in provider retention
			 and termination decisions.
8) WC
			 PPP administrators shall provide those policies and procedures instituted to
			 insure the employer is providing proper notification to the covered employee in
			 accordance with the form promulgated by the Workers' Compensation
			 Commission.