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
2) Descriptions for both the
required standard external review and expedited external review procedures as
set forth within Section 20 of the Act.
3) Statements informing the covered person
and any authorized representative that a standard external review request
deemed to be ineligible for review by the plan or its representative may be
appealed to the Director by filing a complaint with the Director. The health
carrier shall use the following address and provide the following contact
information when directing the covered person or authorized representative to
appeal initial determinations of ineligibility for standard external review:
The Illinois Department of Insurance
Office of Consumer Health Insurance
External Review Unit
320 West Washington Street
Springfield IL 62767
Toll-free Telephone: (877) 527-9431
Fax: (217) 557-8495
Email: doi.externalreview@illinois.gov
Website:
https://mc.insurance.illinois.gov/messagecenter.nsf
4) Statements informing the covered person
and any authorized representative that an expedited external review request
deemed to be ineligible for review by the plan or its representative may be
appealed to the Director by filing a complaint with the Director. The health
carrier shall use the following address when directing the covered person or
authorized representative to appeal initial determinations of ineligibility for
expedited external review:
The Illinois Department of Insurance
Office of Consumer Health Insurance
External Review Unit
320 West 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
5) Special Rules for Multi-State Plans Under
the Marketplace
Pursuant to the U.S. Office of Personnel Management's (OPM)
Multi-State Plan Program regulation at 45 CFR 800.5023, OPM administers the
External Review Process for disputed adverse benefit determinations submitted
by enrollees in Multi-State Plan health insurance options.