Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 240 - HEALTH MAINTENANCE ORGANIZATIONS CODE
Subpart C - HMO OPERATING REQUIREMENTS
Section 240.80 - General Operating Requirements
Current through Register Vol. 48, No. 12, March 22, 2024
a) The HMO operations shall be consistent with the information provided to the Department in the application.
b) The HMO shall appoint a medical director prior to commencing operations. The medical director's credentials shall be submitted to the Department.
c) The HMO shall develop and implement a process which will enable the HMO to maintain current information regarding each provider site under contract with the HMO, including the following:
d) The HMO shall maintain a log that summarizes enrollee grievances and evidences HMO response to those grievances.
e) The HMO's participating physicians, other than those whose scope of practice is limited to radiology, anesthesiology, pathology, or emergency medical services, shall have one of the following:
f) Within six (6) months of commencement of operation, the HMO shall establish operational medical records, quality assessment and utilization review programs as described in Section 240.60 of this Part.
g) The HMO shall inform the Department of the procedure to be used in responding to an enrollee's need for an urgent appointment at a provider site.
h) The HMO shall not cancel an enrollee's membership unless the HMO can present documentation verifying that:
i) In order to exercise the provisions of subsection (h) (4) of this Section, the HMO must notify the enrollee in writing at least 31 days in advance that the HMO considers the physician-patient relationship to be unsatisfactory and has outlined specific changes required to avoid termination.
j) For purposes of subsection (h) of this Section, "material" means a fact or situation which is not merely technical in nature and results or could result in a substantive change in the situation. In addition, the definitions afforded this term by the courts of the State of Illinois shall apply when appropriate to the situation.
k) For purposes of subsection (h) of this Section, "good faith" means honesty of purpose, freedom from intention to defraud and being faithful to one's duty or obligation. In addition, the definitions afforded this term by the courts of the State of Illinois shall apply when appropriate to the situation.