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91_HB2499
LRB9104307JSmg
1 AN ACT to amend the Health Maintenance Organization Act
2 by changing Section 4-6.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Health Maintenance Organization Act is
6 amended by changing Section 4-6 as follows:
7 (215 ILCS 125/4-6) (from Ch. 111 1/2, par. 1408.6)
8 Sec. 4-6. Complaint handling procedure.
9 (a) A Every health maintenance organization shall
10 establish and maintain a complaint system providing
11 reasonable procedures for resolving complaints initiated by
12 enrollees. Nothing herein shall be construed to preclude an
13 enrollee or a provider from filing a complaint with the
14 Director or as limiting the Director's ability to investigate
15 such complaints.
16 (b) When a complaint is received by the Department of
17 Insurance against a health maintenance organization or
18 producer (respondent), the respondent, shall be notified of
19 the complaint. The Department shall, in its notification,
20 specify the date when a report is to be received from the
21 respondent, which shall be no later than 21 days after
22 notification is sent to the respondent. A failure to reply
23 by the date specified may be followed by a collect telephone
24 call or collect telegram. Repeated instances of failing to
25 reply by the date specified may result in further regulatory
26 action.
27 (c) Contents of Response or Report. (1) Each respondent
28 shall supply adequate documentation which explains all
29 actions taken or not taken and which were the basis for the
30 complaint;
31 (2) Documents necessary to support the respondent's
-2- LRB9104307JSmg
1 position and information requested by the Department, shall
2 be furnished with the respondent's reply;
3 (3) The respondent's reply shall be in duplicate, but
4 duplicate copies of supporting documents shall not be
5 required;
6 (4) The respondent's reply shall include the name,
7 telephone number and address of the individual assigned to
8 the complaint; and
9 (5) The Department shall respect the confidentiality of
10 medical reports and other documents which by law are
11 confidential. Any other information furnished by a
12 respondent shall be marked "confidential" if the respondent
13 does not wish it to be released to the complainant.
14 (d) Follow-up Conclusion. Upon receipt of the
15 respondent's report, the investigating deputy shall evaluate
16 the material submitted; and
17 (1) Advise the complainant of the action taken and
18 disposition of his complaint;
19 (2) Pursue further investigation with respondent or
20 complainant; or
21 (3) Refer the investigation report to the appropriate
22 branch within the Department of Insurance for further
23 regulatory action.
24 (Source: P.A. 86-620.)