Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Section 4530.40 - Health Carrier Obligations

Current through Register Vol. 48, No. 28, July 12, 2024
a) Each
			 health carrier shall maintain written records in the aggregate, by state, and
			 for each type of health benefit plan offered by the health carrier on all
			 requests for external review for which the health carrier received notice from
			 the Director for each calendar year. The health carrier shall submit,
			 electronically, a report to the Director, in the format specified by the
			 Director, by June 1 of each year.
b) A health carrier must file with the
			 Director for approval sample copies of:
1)
			 All notices and forms that carriers must provide to covered persons under
			 Sections 20, 25, 35, 40 and 42 of the Act. In addition to those statutory
			 requirements, the following information must be included on notices sent to
			 members in response to member appeals:
A) All
			 notices and forms must prominently display the name, address, toll-free phone
			 number, fax number and appeal email address of the carrier or administrator
			 that handles appeals;
B) All
			 notices and forms shall be specific and limited to information regarding
			 appeals and external review procedures for the member's plan;
C) All notices shall state the number of
			 levels of appeals available (no more than two levels for group and one level
			 for individual) under the plan and will state which level of appeal is
			 applicable to the adverse determination within the notice;
D) All notices shall include the date,
			 including month, day and year, of the adverse determination and, if applicable,
			 the date of the final adverse determination, including month, day and
			 year;
E) All notices shall inform
			 covered persons that the deadlines for filing an appeal or external review
			 request are not postponed or delayed by health care provider appeals unless the
			 health care provider is acting as an authorized representative for the covered
			 person; i.e., the covered person should be filing internal appeals
			 independently and concurrently unless the health care provider has been
			 designated in writing as the authorized representative;
F) All notices shall indicate whether the
			 adverse determination relates to a member appeal (filed by the member or
			 authorized representative who may be the health care provider) or a provider
			 appeal (pursuant to the provider contract) and shall explain timeframes from
			 the date of the adverse determination for the member to appeal and to file an
			 external review regardless of the status of a provider appeal;
G) Upon exhaustion of provider appeals, the
			 notice (which is copied to the member) shall specify timeframes from the date
			 of the final adverse determination for the member to file an appeal or file an
			 external review;
H) Upon exhaustion
			 of internal appeals by the member, the final adverse determination notice shall
			 clearly state that it is the final adverse determination, that all internal
			 appeals have been exhausted, and that the member has 4 months from the date of
			 the letter to file an external review;
I) All notices shall include the following
			 contact information for the Department of Insurance:
Illinois Departments of Insurance
Office of Consumer Health Insurance
External Review Unit
320 W. Washington Street
Springfield IL 62767
Toll-free Telephone: (877) 850-4740
Fax: (217) 557-8495
Email: doi.externalreview@illinois.gov
Website:
https://mc.insurance.illinois.gov/messagecenter.nsf