Illinois Administrative Code
Title 50 - INSURANCE
Part 4521 - HEALTH MAINTENANCE ORGANIZATION
Section 4521.40 - Grievance Procedure
Current through Register Vol. 48, No. 12, March 22, 2024
a) Every HMO shall submit for the Director's approval, and maintain, a system for the resolution of grievances concerning the provision of health care services or other matters concerning operation of the HMO as follows. Each HMO shall:
b) Every HMO shall have a grievance committee with the authority to hear and resolve by majority vote grievances submitted to it as provided in subsection (a).
c) The grievance procedures must be fully and clearly communicated to all enrollees and information concerning grievance procedures shall be readily available to the enrollee.
d) Every HMO shall have simplified procedures for resolving complaints. The procedures do not require review of the complaint by the grievance committee, but a log, file, or other similar records must be maintained to identify the general nature of the complaints. Resolution of complaints shall not preclude the enrollees' rightful access to review by the grievance committee of a grievance.
e) The HMO shall institute procedures that would require grievances to have a determination made by the grievance committee within 60 days from the date the grievance is received by the HMO. A grievance may not be heard or voted upon unless at least 50% of the voting individuals of the committee are enrollees. The determination by the grievance committee may be extended for a period not to exceed 30 days in the event of a delay in obtaining the documents or records necessary for the resolution of the grievance. All requests for documents or records necessary for the resolution of the grievance shall be maintained in the HMO's grievance file.
f) The grievance procedure shall provide the enrollee with a written acknowledgment of the grievance within 10 business days after receipt by the HMO.
g) The enrollee shall be notified at the time of the hearing of the name and affiliation of those grievance committee members who are representatives of the HMO.
h) The HMO shall institute procedures whereby any documentation furnished to the members of the grievance committee shall also be made available to the enrollee not less than 5 business days prior to the hearing of the grievance. The HMO shall not present any evidence without the enrollee having been given the opportunity to be present.
i) Notification in writing of the determination of the grievance committee shall be mailed to the enrollee within 5 business days after the determination. Notice of the determination made at the final appeal step of the HMO's grievance process shall include a Notice of Availability of the Department that the HMO shall send to its enrollees explaining that the Department is available to respond to their inquiries.
j) Prior to the resolution of a grievance filed by a subscriber or enrollee, coverage shall not be terminated for any reason that is the subject of the written grievance, except when the HMO has, in good faith, made a reasonable effort to resolve the written grievance through its grievance procedure and coverage is being terminated as provided for in Section 5421.111 of this Part.