(215 ILCS 125/4-6)
(from Ch. 111 1/2, par. 1408.6)
Complaint handling procedure.
(a) Every health maintenance
organization shall establish and maintain a complaint system providing
reasonable procedures for resolving complaints initiated by enrollees.
Nothing herein shall be construed to preclude an enrollee or a
provider from filing a complaint with the Director or as limiting the
Director's ability to investigate such complaints.
(b) When a complaint is received
by the Department of Insurance against a health maintenance organization or
producer (respondent), the respondent, shall be notified of the
complaint. The Department shall, in its notification, specify the date when
a report is to be received from the respondent, which shall be no later
than 21 days after notification is sent to the respondent. A failure to
reply by the date specified may be followed by a collect telephone call or
collect telegram. Repeated instances of failing to reply by the date
specified may result in further regulatory action.
(c) Contents of Response or Report. (1) Each respondent shall supply
adequate documentation which explains all actions taken or not taken and
which were the basis for the complaint;
(2) Documents necessary to support the respondent's position and
information requested by the Department, shall be furnished with the
(3) The respondent's reply shall be in duplicate, but duplicate copies
of supporting documents shall not be required;
(4) The respondent's reply shall include the name, telephone number and
address of the individual assigned to the complaint; and
(5) The Department shall respect the confidentiality of medical reports
and other documents which by law are confidential. Any other information
furnished by a respondent shall be marked "confidential" if the respondent
does not wish it to be released to the complainant.
(d) Follow-up Conclusion. Upon receipt of the respondent's report, the
investigating deputy shall evaluate the material submitted; and
(1) Advise the complainant of the action taken and disposition of his
(2) Pursue further investigation with respondent or complainant; or
(3) Refer the investigation report to the appropriate branch within the
Department of Insurance for further regulatory action.
(Source: P.A. 86-620.)