Current through Register Vol. 48, No. 12, March 22, 2024
1. Column A. Health Care Plan Identification
Number - This is the identification number used by the health care plan to
identify the complaint internally. The identification number must be unique for
each complaint.
2. Column B.
Complaint Origin - complaint was filed by:
a)
Consumer or enrollee;
b)
Provider;
c) Any other
individual.
3. Column C.
Function Code. Complaints are to be classified by functions or the health care
plan involved, as follows:
a) Denial of care
or treatment (dissatisfaction regarding prospective non-authorization of a
request for care or treatment recommended by a provider excluding diagnostic
procedures and referral requests; partial approvals and care terminations are
also considered to be denials);
b)
Denial of diagnostic procedure (dissatisfaction regarding prospective
non-authorization of a request for a diagnostic procedure recommended by a
provider; partial approvals are also considered to be denials);
c) Denial of referral request
(dissatisfaction regarding non-authorization of a request for a referral to
another provider recommended by a PCP);
d) Sufficient choice and accessibility of
health care providers (dissatisfaction by an enrollee or policyholder regarding
the extent to which the health care plan has practitioners/providers of the
appropriate type and number distributed geographically to meet the needs of the
member; in addition, dissatisfaction by an enrollee or policyholder regarding
the extent to which the enrollee or policyholder may obtain available services
at the time they are needed - available service refers to both telephone access
and ease of scheduling an appointment);
e) Underwriting (dissatisfaction by an
enrollee or policyholder regarding the health care plan's process of examining,
accepting, or rejecting insurance risks and classifying those selected in order
to charge the proper premiums for each);
f) Marketing and sales (dissatisfaction
regarding solicitation or the sale of a policy by the managed care
organization; solicitation means any method by which information relative to
the health care plan is made known to the public for the purpose of informing
or influencing potential enrollees to enroll in the health care plan,
regardless of the media or technique used);
g) Claims and utilization review
(dissatisfaction regarding the concurrent or retrospective evaluation of the
coverage, medical necessity, efficiency or appropriateness of health care
services or treatment plans; prospective "Denials of care or treatment,"
"Denials of diagnostic procedures" and "Denials of referral requests" should
not be classified in this category, but the appropriate one above);
h) Member services (dissatisfaction by an
enrollee or policyholder related to response time regarding provision of
information; handling of a complaint, appeal or external review; or any
interaction between plan representatives and enrollee);
i) Provider relations:
I) Quality of Care (dissatisfaction regarding
any aspect of care provider by an institution or organization or practitioner
that provides services to a managed care organization's members; this category
does not include sufficient choice or accessibility of a provider);
II) Provider complaints - Prompt Pay
(complaints by providers (prompt pay, etc.), excluding those filed under
"Denials of care or treatment," "Denials of diagnostic procedures" and "Denials
of referral request" above);
j) Miscellaneous (any "complaint", as defined
above, not falling in one of the above categories).
4. Column D. Date Received - date received by
the health care plan.
5. Column E.
Date Closed - date closed by the health care plan.
6. Column F. Illinois Department of Insurance
Complaint File Number - If the complaint was also sent to the health care plan
from the Department, the health care plan should provide the IDOI complaint
number in this column.
7. Column G.
Illinois Department of Insurance Complaint File Closed Date. The Department
will provide the company with the date the complaint was closed by the
Department.
8. Column H. External
Review - indicate by placing an "X" in the column if complaint was processed
through external review procedure.
9. Column I. Disposition.
a) Relief Granted - If the complaint was
resolved in favor of the complainant;
b) Partial Relief Granted - If the complaint
was only partially resolved in favor of the complainant;
c) Information Furnished - The complaint did
not require action, only information to be provided to the enrollee;
d) No Relief Granted - If the complaint was
not resolved in favor of the complainant.
