Section 4520.10  Purpose

 

This Part will implement the Managed Care Reform and Patient Rights Act [215 ILCS 134] in order to assure:  the proper provision of information to enrollees by health care plans; the proper treatment of enrollees by health care plans; the proper treatment of health care providers by health care plans; and the proper oversight of health care plans by the Department of Insurance.

 

(Source:  Amended at 34 Ill. Reg. 6879, effective April 29, 2010)

 

Section 4520.20  Applicability and Scope

 

The requirements of this Part are applicable to:

 

a)         Policies and contracts amended, delivered, issued, or renewed by health care plans pursuant to the Act; and

 

b)         The program of health benefits under the State Employees Group Insurance Act, with the exception of the fee for service program which only needs to comply with Section 85 and the definition of "emergency medical condition" contained in Section 10 of the Act; the Counties Code; the Illinois Municipal Code; the Comprehensive Health Insurance Plan Act; the Health Maintenance Organization Act; the Limited Health Service Organization Act, except for plans offering only dental services, or only vision services; the Voluntary Health Services Plans Act; and the medical assistance program and other programs administered by the Department of Public Aid under the Illinois Public Aid Code, except that complaints shall be handled consistent with the requirements of Section 4520.80(a) of this Part; and

 

c)         Third party administrators, as defined in Article XXXI¼ of the Code, and entities regulated under Article XX½ of the Code, generally referred to as Preferred Provider Organizations (PPOs) must comply with the requirements of Section 4520.90 and Exhibit A of this Part pursuant to Section 55 of the Act; and

 

d)         Any person who conducts a utilization review program in this State, except that the provisions of Section 85 of the Act are not applicable to bodily injury liability claims (including uninsured motorist and underinsured motorist coverage claims) arising under property and casualty contracts issued under Class 2 and Class 3 of Section 4 of the Code [215 ILCS 5/4] and does not include the retrospective review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment.  Section 85 is also specifically applicable to third party administrators, PPOs and insurance companies that transact the kinds of insurance authorized under Class 1(b) or Class 2(a) of Section 4 of the Code.  For purposes of this Part, an entity shall be considered to be conducting a utilization review program in this State if it evaluates the use of health care services, procedures, and facilities by persons who are either covered under contracts of insurance entered into in this State, or enrolled in an entity licensed pursuant to the Health Maintenance Organization Act, the Limited Health Service Organization Act or the Voluntary Health Services Plans Act; and

 

e)         Preferred provider administrators, as defined in Section 370g(g) of the Code, and insurance companies that transact the kinds of insurance authorized under Class 1(b) or Class 2(a) of Section 4 of the Code must also comply with the definition of the term emergency medical condition, as defined in Section 10 of the Act. 

 

(Source:  Amended at 28 Ill. Reg. 13711, effective September 28, 2004)

 

Section 4520.30  Definitions

 

"Act" means the Managed Care Reform and Patient Rights Act [215 ILCS 134].

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Department" means the Illinois Department of Insurance.

 

"Director" means the Director of the Illinois Department of Insurance.

 

"Health Care Plan" means a plan that establishes, operates, or maintains a network of health care providers that has entered into an agreement with the plan to provide health care services to enrollees to whom the plan has the ultimate obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution.  Nothing in this definition shall be construed to mean that an independent practice association or a physician hospital organization that subcontracts with a health care plan is, for purposes of that subcontract, a health care plan.  For purposes of this definition, "health care plan" shall not include the following:

 

indemnity health insurance policies including those using a contracted provider network;

 

health care plans that offer only dental or only vision coverage;

 

preferred provider administrators, as defined in Section 370g(g) of the Illinois Insurance Code;

 

employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974;

 

health care provided pursuant to the Workers' Compensation Act or the Workers' Occupational Diseases Act; and

 

not-for-profit voluntary health services plans with health maintenance organization authority in existence as of January 1, 1999 that are affiliated with a union and that only extend coverage to union members and their dependents.

 

"Health Care Provider" means any physician, hospital facility, nursing home or other person that is licensed or otherwise authorized to deliver health care services. Nothing in the Act shall be construed to define independent practice associations or physician hospital organizations as health care providers.

 

"Long-Standing Relationship" means the continuous relationship between an enrollee and his or her primary care physician of not less than 5 years; except in the case of a child 5 years or under who has had a continuous relationship with the same primary care physician since birth, placement for adoption, guardianship or foster care.

 

"Managed Care Organization" or "MCO" means a partnership, association, corporation or other legal entity, including but not limited to individual practice associations (IPAs) and Physician Hospital Organizations (PHOs), which delivers or arranges for the delivery of health care services through providers it has contracted with or otherwise made arrangements with to furnish such health care services.

 

"Nursing Home" means a skilled nursing care facility that is subject to licensure by the Illinois Department of Public Health under the Nursing Home Care Act [210 ILCS 45].

 

"Ongoing Course of Treatment" means the treatment of a condition or disease that requires repeated health care services pursuant to a plan of treatment by a physician because of the potential for changes in the therapeutic regimen.

 

"Person" means a corporation, association, partnership, limited liability company, sole proprietorship, or any other legal entity.

 

"Referral Arrangement" means that, for each referral or standing referral, a referral arrangement exists between a participating primary care physician and a participating specialist physician or a participating health care provider when a participating primary care physician makes a referral of an enrollee for that referral or standing referral to a participating specialist physician or participating health care provider.

 

"Standing Referral" means a written referral from the primary care physician for an ongoing course of treatment pursuant to a treatment plan specifying needed services and time frames developed by a specialist in consultation with the primary care physician and in accordance with procedures developed by the health care plan.

 

"Utilization Review" means the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities.

 

"Utilization Review Organization" or "URO" means an entity that has established one or more utilization review programs.  This definition does not include:

 

persons providing utilization review program services only to the federal government;

 

self-insured health plans under the Federal Employee Retirement Income Security Act of 1974 (ERISA); however, this Part does not apply to persons conducting a utilization review program on behalf of these health plans;

 

hospitals and medical groups performing utilization review activities for internal purposes; however, this Part does apply when the hospital or medical group is conducting utilization review for another person.

 

"Utilization Review Program" means a program established by a person to perform utilization review.

 

(Source:  Amended at 43 Ill. Reg. 11479, effective September 24, 2019)

 

Section 4520.40  Provision of Information

 

Description of Coverage

A written summary of benefits and coverage (SBC) in accordance with 50 Ill. Adm. Code 2001.10, must be provided to the enrollee by the health care plan. 

 

(Source:  Amended at 38 Ill. Reg. 2253, effective January 2, 2014)

 

Section 4520.50  Notice of Nonrenewal or Termination

 

a)         All provider agreements shall provide for at least 60 days notice by the provider for termination with cause, as defined in the provider agreement, and at least 90 days notice by the provider for termination without cause.  Upon receipt of the notice, the health care plan shall notify enrollees within 30 days after the termination and the proper steps to be taken for selecting a new health care provider.  In the event the provider violates the provider agreement and does not give a notice of termination in the appropriate timeframe, the health care plan must provide immediate notice to the enrollees.  The health care plan must inform the Department  immediately of any known or intended termination, with or without cause, of an MCO.

 

b)         A health care plan must give at least 60 days notice of nonrenewal or termination of a health care provider to the health care provider and to the enrollees served by the health care provider.  The notice shall include a name and address to which an enrollee or health care provider may direct comments and concerns regarding the nonrenewal or termination.  Immediate written notice may be provided without 60 days notice when a health care provider's license has been disciplined by a State licensing board.  The notice shall inform the enrollee of the availability of transitional services and that the enrollee must request transitional services within 30 days from receipt of this notice.

 

(Source:  Amended at 38 Ill. Reg. 2253, effective January 2, 2014)

 

Section 4520.60  Transition of Services

 

a)         Health care plans shall notify new enrollees and current enrollees of the availability of transitional services for conditions that require ongoing course of treatment.

 

b)         New enrollees must request the option of transitional services in writing, within 15 days after receiving notification of the availability of transitional services, through a mechanism established by the health care plan.

 

c)         Enrollees whose physician leaves the health care plan's network of health care providers shall request the option of transitional services in writing within 30 days after receipt of notification of termination of the physician.

 

d)         Within 15 days after receiving such notification from the enrollee, the health care plan shall notify the enrollee if a denial is issued for the enrollee's request of transitional services based on the enrollee's physician refusing to agree to accept the health care plan's reimbursement rates, adhere to the health care plan's quality assurance requirements, provide the health care plan with necessary medical information related to the enrollee's care, or otherwise adhere to the health care plan's policies and procedures.  The notification shall be in writing and include the specific reason for such denial.

 

Section 4520.70  Health Care Services, Appeals, Complaints and External Independent Reviews

 

a)         A plan shall implement an effective appeals process for appeals of coverage determinations and claims, under which the health care plan shall, at a minimum:

 

1)         have in effect an internal claims appeal process;

 

2)         provide notice to enrollees, in a culturally and linguistically appropriate    manner, of available internal and external appeals processes, and the availability of Department consumer assistance to assist enrollees with the appeals processes; and

 

3)         allow an enrollee to review his or her file, to present evidence and testimony as  part of the appeals process, and to receive continued coverage pending the outcome of the appeals process. (Section 2719 of the Public Health Service Act; 42 USC 201 et seq.)

 

b)         A plan shall affirm or deny liability on claims within a reasonable time and shall offer payment within 30 days after affirmation of liability, if the amount of the claim is determined and not in dispute.  For those portions of the claim that are not in dispute and the payee is known, the plan shall tender payment within the 30 days.

 

c)         If a settlement of a claim is less than the amount claimed, or if the claim is denied, the plan shall provide to the insured a reasonable written explanation of the basis of the lower offer or denial within 30 days after the investigation and determination of liability is completed.  This explanation shall clearly set forth the policy definition, limitation, exclusion or condition upon which denial was based.  The explanation shall clearly inform the enrollee of the right to appeal the claim reduction or denial, the process by which the enrollee (or the enrollee's designee or guardian) may initiate the appeal process and the plan's phone number to call to receive more information concerning the appeal process.  Notice of Availability of the Department shall accompany this explanation.

 

d)         A health plan shall ensure that an enrollee (or the enrollee's designee or guardian) has a period of not less than 180 days after the date of the explanation of a denial of a claim for benefits in which to appeal the denial under this Section.  The only exception to this requirement is those complaints that are handled by the Department of Healthcare and Family Services (HFS), consistent with the requirements of Section 4520.80(a).

 

 (Source:  Amended at 38 Ill. Reg. 2253, effective January 2, 2014)

 

Section 4520.80  Joint Resolution of Complaints – Department of Insurance and Department of Public Health − Notification and Resolution Process

 

a)         Complaints against health care plans participating in programs administered by the Department of Healthcare and Family Services (HFS) pursuant to the Public Aid Code shall be resolved under rules published by HFS.  Any complaints against such plans received by the Department of Insurance or the Department of Public Health shall be referred to HFS.

 

b)         Any enrollee or health care provider, on behalf of the enrollee, may file a written complaint against the health care plan through the Department of Insurance.  Complaints received by the Department of Public Health shall be referred to the Department of Insurance for processing prior to investigation.

 

c)         The health care plan response shall include documentation and an explanation of all actions taken or not taken that were the basis for the complaint.  The respondent shall include documents necessary to support the respondent's position and any additional information requested by the Department of Insurance and/or the Department of Public Health.  Both the Department of Insurance and the Department of Public Health shall maintain confidentiality of medical records and other pertinent documents.

 

d)         Quality of care complaints may be referred to the Department of Public Health for investigation.

 

1)         The Department of Public Health shall determine if an on-site investigation is warranted and may request additional information from the complainant, health care provider, or health care plan if the information provided is determined to be incomplete or if additional information is needed to make a determination regarding the complaint.

 

2)         If an investigation is warranted, the Department of Public Health shall make available the name, address and telephone number where an enrollee may obtain the status of the complaint.

 

3)         The Department of Public Health shall forward the findings of the investigation to the Department for final disposition and record keeping.

 

e)         No Department of Insurance or Department of Public Health publication or release of information shall identify any enrollee, health care provider, or individual complainant.

 

(Source:  Amended at 34 Ill. Reg. 6879, effective April 29, 2010)

 

Section 4520.90  Record of Complaints

 

a)         Complaint, as used in this Section, means any communication primarily expressing a grievance to the health care plan by, or on behalf of, the enrollee, or by the health care provider.  For purposes of this definition, "communication" shall include the following:

 

1)         A written notice relating to the health care plan's determinations, procedures and administration as stated in Sections 45 and 50 of the Act; and

 

2)         Written or oral notice filed under the expedited health care services appeal process or under the utilization review process.

 

b)         The health care plan shall submit to the Director  a report by April 1 for the previous calendar year that shall include a record of the plan's complaints in the format prescribed in Exhibit A.  Beginning April 1, 2005, all plans or companies must electronically submit the record of complaints to the Director in a format prescribed by the Director.

 

c)         Any plan or company failing to file a complaint report by April 1 for the previous calendar year may be subject to a late fee of $100 for each day the report is late.

 

(Source:  Amended at 38 Ill. Reg. 2253, effective January 2, 2014)

 

Section 4520.100  Access and Quality of Care from Providers Without Primary Care Physician Referral or Authorization

 

a)         Health care plans that allow enrollees to access health care services from contractual providers without a referral or authorization from the primary care physician (PCP) shall have in place a system for centralized record keeping to track and monitor the provider/enrollee encounters to assure that enrollees are receiving needed services.

 

b)         The health care plan's centralized record keeping system for access and quality of care shall be described in detail, filed with and deemed acceptable by the Director of Public Health.  The Director of Public Health shall forward a copy of the approved system for record keeping and the notice of his or her final action with the Department of Insurance.

 

c)         The health care plan shall be able to retrieve an enrollee's centralized record of the provider/enrollee encounters for review by the Department and/or Department of Public Health as part of a complaint investigation or inquiry.

 

(Source:  Amended at 34 Ill. Reg. 6879, effective April 29, 2010)

 

Section 4520.110  Emergency Services

 

a)         For purposes of determining compliance with Section 65 of the Act, timely determination shall mean a determination is made within 30 days after the health care plan receives a claim for emergency services if no additional information is needed to determine the emergency services meet the definition of an emergency medical condition.  In the event additional information is necessary to make the determination, the health care plan shall request the medical record documenting the presenting symptoms at the time care was sought within 15 days after receipt of the emergency services claim and make a determination within 30 days after its receipt.

 

b)         If a group health care plan offering group or individual health insurance, provides or covers any benefits with respect to services in an emergency department of a hospital, the plan shall cover emergency services in a manner that those services will be provided without imposing a requirement under the plan for prior authorization of services or any limitation on coverage when the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan.

 

c)         In addition to complying with the coverage requirements provided in 50 Ill. Adm. Code 2051.310(a)(6)(J), if emergency services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if the services were provided in-network. (Section 2719A(b) and (c)(ii) of the Public Health Service Act (42 USC 300 gg-19(1)))

 

(Source:  Amended at 38 Ill. Reg. 2253, effective January 2, 2014)

 

Section 4520.120  Post Stabilization Services

 

For purposes of determining compliance with Section 70 of the Act, timely determination shall mean a determination is made within 30 days after the health care plan receives a claim for post stabilization services if no additional information is needed to determine that services rendered were not contrary to the instructions of the health care plan or its delegated health care provider if the contact was made between those parties and the treating health care provider prior to the services being rendered.  In the event additional information is necessary to make such a determination, the health care plan shall request  the medical record documenting the time, phone number dialed,  and the result of the communication for request for authorization of post stabilization medical services as well as the post stabilization medical services rendered within 15 days after receipt of the post stabilization services claim and make a determination within 30 days after its receipt.

 

Section 4520.130  Registration of Utilization Review Organizations

 

a)         Registration:  On or after July 1, 2000, a URO may not conduct utilization review for persons subject to Section 85 of the Act unless the URO has registered with the Director.  An application for registration shall be made using the standard form available on the Department website (https://insurance.illinois.gov), and must be signed by an officer or director of the URO.  Initial registration applications shall be deemed approved unless the Director finds the application to be noncompliant with either the standards set forth in Section 85 of the Act or this Part.

 

b)         The application for registration shall include, but not be limited to, the following information: applicant's identifying and contact information; applicant's agent for service of process in Illinois; applicant's accreditation status; signed affirmation by an officer or director; and for each utilization review program: contact information and business hours; organization and governing structure; number of reviews in Illinois for the current and previous years; description of the grievance process; written policies and procedures for protection of confidential information; and biographical information for officers and directors.  The Department will accept the biographical affidavit, and any supplement to that affidavit, that is obtained from the website of the National Association of Insurance Commissioners (NAIC) or the Department.

 

c)         Fees:  A URO must register with the Director every two years.  A fee of $3,000 must be submitted with each application or renewal unless the URO is accredited by URAC (formerly Utilization Review Accreditation Commission), the National Committee for Quality Assurance (NCQA), The Joint Commission (JCAHO), or the Accreditation Association for Ambulatory Health Care (AAAHC), in which case the fee is $1500.

 

d)         Any material changes in the information filed pursuant to this Part shall be filed with the Director within 30 days after the change.  Loss of accreditation status will require re-registration and payment of a $3000 fee pursuant to subsections (a) and (b).

 

e)         Renewals and Appeals:

 

1)         A registered URO may continue to operate, if the application and fee have been filed 30 days prior to the renewal date, until the renewal is denied or issued by the Director.

 

2)         If the renewal application and fee are not received prior to the renewal date, the registration will automatically expire and the URO must re-register and pay a fee pursuant to subsections (a) and (b).

 

3)         If an application for registration or renewal is denied under this Part, the applicant may appeal that denial by requesting a hearing under Article 10 of the Illinois Administrative Procedure Act [5 ILCS 100] and 50 Ill. Adm. Code 2402. A petition for hearing must be postmarked no later than 30 days after the date of initial denial.  A hearing shall be scheduled within 45 days after the petition is filed with the Director.  A decision by the Director shall be rendered within 60 days after the close of the hearing.

 

(Source:  Amended at 46 Ill. Reg. 9881, effective May 31, 2022)

 

Section 4520.140  Operational Requirements

 

A URO shall comply with all URAC standards except when specifically addressed by Sections 45 and 50 of the Act for health care plans.  The terms in Sections 45 and 50 of the Act shall have the meaning assigned by the Act.  Utilization review decisions shall be issued pursuant to the Managed Care Reform and Patient Rights Act [215 ILCS 134].

 

(Source:  Amended at 43 Ill. Reg. 11479, effective September 24, 2019)

Section 4520.EXHIBIT A   Complaint Record and Column Descriptions

 

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.

 

(Source:  Amended at 38 Ill. Reg. 2253, effective January 2, 2014)

Section 4520.EXHIBIT B   Application for Registration of a Utilization Review Organization (Repealed)

 

(Source:  Repealed at 46 Ill. Reg. 9881, effective May 31, 2022)

Section 4520.EXHIBIT C   Utilization Review Organization Officers and Directors Biographical Affidavit (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11479, effective September 24, 2019)

Section 4520.EXHIBIT D   NAIC Utilization Review Organization Officers and Directors Biographical Affidavit (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11479, effective September 24, 2019)