Section 5420.70  Health Care Services, Appeals, Complaints and External Independent Reviews

a)         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.

b)         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 Division of Insurance shall accompany this explanation.

c)         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 such denial under this Section.  The only exception to this requirement are those complaints that are handled by IDPA consistent with the requirements of Section 5420.80(a) of this Part.

d)         Every health care plan shall submit for the Division's review, and thereafter maintain, a mechanism for the joint selection of the external independent reviewer.  Any proposed changes to the mechanism must be filed for review by the Division.

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