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90_HB3267
New Act
Creates the Managed Care Grievance Procedure Act. Sets
forth the procedures managed care plans must follow when
handling a grievance filed by an enrollee. Establishes a
multi-level grievance review system. Provides for an
external review before an independent reviewer if requested
by an enrollee. Requires a managed care plan to maintain a
register of all complaints filed within the 3 previous years
and to report to the Department of Public Health.
LRB9011443JSmg
LRB9011443JSmg
1 AN ACT relating to grievance procedures of managed care
2 plans.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 1. Short title. This Act may be cited as the
6 Managed Care Grievance Procedure Act.
7 Section 5. Definitions. For purposes of this Act, the
8 following words shall have the meanings provided in this
9 Section, unless otherwise indicated:
10 "Adverse determination" means a determination by a
11 utilization review agent that an admission, extension of a
12 stay, or other health care service has been reviewed and,
13 based on the information provided, is not medically
14 necessary.
15 "Clinical peer reviewer" or "clinical personnel" means:
16 (1) in the case of physician reviewers, a State
17 licensed physician who is of the same category in the
18 same or similar specialty as the health care provider who
19 typically manages the medical condition, procedure or
20 treatment under review; or
21 (2) in the case of non-physician reviewers, a State
22 licensed or registered health care professional who is
23 in the same profession and same or similar specialty
24 as the health care provider who typically manages the
25 medical condition, procedure, or treatment under review.
26 Nothing herein shall be construed to change any
27 statutorily defined scope of practice.
28 "Degenerative or disabling condition or disease" means a
29 condition or disease that is permanent or of indefinite
30 duration, that is likely to become worse or more advanced
31 over time, and that substantially impairs a major life
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1 function.
2 "Department" means the Department of Public Health.
3 "Director" means the Director of Public Health.
4 "Enrollee" means a person enrolled in a managed care
5 plan.
6 "Health care professional" means a physician, registered
7 professional nurse, or other person appropriately licensed or
8 registered pursuant to the laws of this State to provide
9 health care services.
10 "Health care provider" means a health care professional,
11 hospital, facility, or other person appropriately licensed or
12 otherwise authorized to furnish health care services or
13 arrange for the delivery of health care services in this
14 State.
15 "Health care services" means services included in the (i)
16 furnishing of medical care, (ii) hospitalization incident to
17 the furnishing of medical care, and (iii) furnishing of
18 services, including pharmaceuticals, for the purpose of
19 preventing, alleviating, curing, or healing human illness or
20 injury to an individual.
21 "Managed care plan" means a plan that establishes,
22 operates, or maintains a network of health care providers
23 that have entered into agreements with the plan to provide
24 health care services to enrollees where the plan has the
25 obligation to the enrollee to arrange for the provision of or
26 pay for services through:
27 (1) organizational arrangements for ongoing quality
28 assurance, utilization review programs, or dispute
29 resolution; or
30 (2) financial incentives for persons enrolled in
31 the plan to use the participating providers and
32 procedures covered by the plan.
33 A managed care plan may be established or operated by any
34 entity including, but not necessarily limited to, a licensed
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1 insurance company, hospital or medical service plan, health
2 maintenance organization, limited health service
3 organization, preferred provider organization, third party
4 administrator, independent practice association, or employer
5 or employee organization.
6 For purposes of this definition, "managed care plan"
7 shall not include the following:
8 (1) strict indemnity health insurance policies or
9 plans issued by an insurer that does not require approval
10 of a primary care provider or other similar coordinator
11 to access health care services; and
12 (2) managed care plans that offer only dental or
13 vision coverage.
14 "Primary care provider" means a physician licensed to
15 practice medicine in all its branches who provides a broad
16 range of personal medical care (preventive, diagnostic,
17 curative, counseling, or rehabilitative) in a comprehensive
18 and coordinated manner over time for a managed care plan.
19 Section 10. General grievance procedure.
20 (a) A managed care plan shall establish and maintain a
21 grievance procedure, as described in this Act. Compliance
22 with this Act's grievance procedures shall satisfy a managed
23 care plan's obligation to provide grievance procedures under
24 any other State law or rules.
25 A copy of the grievance procedures, including all forms
26 used to process a grievance, shall be filed with the
27 Director. Any subsequent material modifications to the
28 documents also shall be filed. In addition, a managed care
29 plan shall file annually with the Director a certificate of
30 compliance stating that the managed care plan has established
31 and maintains, for each of its plans, grievance procedures
32 that fully comply with the provisions of this Act. The
33 Director has authority to disapprove a filing that fails to
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1 comply with this Act or applicable rules.
2 (b) A managed care plan shall provide written notice of
3 the grievance procedure to all enrollees in the member
4 handbook and to an enrollee at any time that the managed care
5 plan denies access to a referral or determines that a
6 requested benefit is not covered pursuant to the terms of the
7 contract. In the event that a managed care plan denies a
8 service as an adverse determination, the managed care plan
9 shall inform the enrollee or the enrollee's designee of
10 the appeal rights under this Act.
11 The notice to an enrollee describing the grievance
12 process shall explain the process for filing a grievance
13 with the managed care plan, the timeframes within which a
14 grievance determination must be made, and the right of an
15 enrollee to designate a representative to file a grievance on
16 behalf of the enrollee. Information required to be disclosed
17 or provided under this Section must be provided in a
18 reasonable and understandable format.
19 The managed care plan shall assure that the grievance
20 procedure is reasonably accessible to those who do not speak
21 English.
22 (c) A managed care plan shall not retaliate or take
23 any discriminatory action against an enrollee because an
24 enrollee has filed a grievance or appeal.
25 Section 15. First level grievance review.
26 (a) The managed care plan may require an enrollee to
27 file a grievance in writing, by letter or by a grievance
28 form which shall be made available by the managed care plan,
29 however, an enrollee must be allowed to submit an oral
30 grievance in connection with (i) a denial of, or failure to
31 pay for, a referral or service or (ii) a determination as to
32 whether a benefit is covered pursuant to the terms of the
33 enrollee's contract. In connection with the submission of
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1 an oral grievance, a managed care plan shall, within 24
2 hours, reduce the complaint to writing and give the enrollee
3 written acknowledgment of the grievance prepared by the
4 managed care plan summarizing the nature of the grievance
5 and requesting any information that the enrollee needs to
6 provide before the grievance can be processed. The
7 acknowledgment shall be mailed within the 24-hour period
8 to the enrollee, who shall sign and return the
9 acknowledgment, with any amendments and requested
10 information, in order to initiate the grievance. The
11 grievance acknowledgment shall prominently state that the
12 enrollee must sign and return the acknowledgment to
13 initiate the grievance. A managed care plan may elect not to
14 require a signed acknowledgment when no additional
15 information is necessary to process the grievance, and an
16 oral grievance shall be initiated at the time of the
17 telephone call.
18 Except as authorized in this subsection, a managed care
19 plan shall designate personnel to accept the filing of an
20 enrollee's grievance by toll-free telephone no less than
21 40 hours per week during normal business hours and shall
22 have a telephone system available to take calls during other
23 than normal business hours and shall respond to all such
24 calls no later than the next business day after the call was
25 recorded. In the case of grievances subject to item (i) of
26 subsection (b) of this Section, telephone access must be
27 available on a 24 hour a day, 7 day a week basis.
28 (b) Within 48 hours of receipt of a written grievance,
29 the managed care plan shall provide written acknowledgment
30 of the grievance, including the name, address,
31 qualifying credentials, and telephone number of the
32 individuals or department designated by the managed care plan
33 to respond to the grievance. All grievances shall be
34 resolved in an expeditious manner, and in any event, no more
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1 than (i) 24 hours after the receipt of all necessary
2 information when a delay would significantly increase the
3 risk to an enrollee's health or when extended health care
4 services, procedures, or treatments for an enrollee
5 undergoing a course of treatment prescribed by a health care
6 provider are at issue, (ii) 15 days after the receipt of all
7 necessary information in the case of requests for referrals
8 or determinations concerning whether a requested benefit
9 is covered pursuant to the contract, and (iii) 30 days after
10 the receipt of all necessary information in all other
11 instances.
12 (c) The managed care plan shall designate one or more
13 qualified personnel to review the grievance. When the
14 grievance pertains to clinical matters, the personnel shall
15 include, but not be limited to, one or more appropriately
16 licensed or registered health care professionals.
17 (d) The notice of a determination of the grievance
18 shall be made in writing to the enrollee or to the enrollee's
19 designee. In the case of a determination made in conformance
20 with item (i) of subsection (b) of this Section, notice
21 shall be made by telephone directly to the enrollee with
22 written notice to follow within 2 business days.
23 (e) The notice of a determination shall include (i)
24 clear and detailed reasons for the determination, including
25 any contract basis for the determination, and the evidence
26 relied upon in making that determination, (ii) in cases where
27 the determination has a clinical basis, the clinical
28 rationale for the determination, and (iii) the procedures for
29 the filing of an appeal of the determination, including a
30 form for the filing of an appeal.
31 Section 20. Second level grievance review.
32 (a) A managed care plan shall establish a second level
33 grievance review process to give those enrollees who are
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1 dissatisfied with the first level grievance review decision
2 the option to request a second level review, at which the
3 enrollee shall have the right to appear in person before
4 authorized individuals designated to respond to the appeal.
5 (b) An enrollee or an enrollee's designee shall
6 have not less than 60 days after receipt of notice of the
7 grievance determination to file a written appeal, which may
8 be submitted by letter or by a form supplied by the managed
9 care plan. The enrollee shall indicate in his or her written
10 appeal whether he or she wants the right to appear in person
11 before the person or panel designated to respond to the
12 appeal.
13 (c) Within 48 hours of receipt of the second level
14 grievance review, the managed care plan shall provide written
15 acknowledgment of the appeal, including the name, address,
16 qualifying credentials, and telephone number of the
17 individual designated by the managed care plan to respond
18 to the appeal and what additional information, if any, must
19 be provided in order for the managed care plan to render a
20 decision.
21 (d) The determination of a second level grievance review
22 on a clinical matter must be made by personnel qualified
23 to review the appeal, including appropriately licensed or
24 registered health care professionals who did not make
25 the initial determination, a majority of whom must be
26 clinical peer reviewers. The determination of a second
27 level grievance review on a matter that is not clinical shall
28 be made by qualified personnel at a higher level than the
29 personnel who made the initial grievance determination.
30 (e) The managed care plan shall seek to resolve all
31 second level grievance reviews in the most expeditious manner
32 and shall make a determination and provide notice no more
33 than (i) 24 hours after the receipt of all necessary
34 information when a delay would significantly increase the
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1 risk to an enrollee's health or when extended health care
2 services, procedures, or treatments for an enrollee
3 undergoing a course of treatment prescribed by a health care
4 provider are at issue and (ii) 30 business days after the
5 receipt of all necessary information in all other instances.
6 (f) The notice of a determination on a second level
7 grievance review shall include (i) the detailed reasons for
8 the determination, including any contract basis for the
9 determination and the evidence relied upon in making the
10 determination and (ii) in cases where the determination has a
11 clinical basis, the clinical rationale for the
12 determination.
13 (g) If an enrollee has requested the opportunity to
14 appear in person before the authorized representatives of the
15 managed care plan designated to respond to the appeal, the
16 review panel shall schedule and hold a review meeting within
17 30 days of receiving a request from an enrollee for a second
18 level review with a right to appear. The review meeting
19 shall be held during regular business hours at a location
20 reasonably accessible to the enrollee. The enrollee shall be
21 notified in writing at least 14 days in advance of the review
22 date.
23 Upon the request of an enrollee, a managed care plan
24 shall provide to the enrollee all relevant information that
25 is not confidential or privileged.
26 An enrollee has the right to:
27 (1) attend the second level review;
28 (2) present his or her case to the review panel;
29 (3) submit supporting material both before and at
30 the review meeting;
31 (4) ask questions of any representative of the
32 managed care plan; and
33 (5) be assisted or represented by persons of his or
34 her choice.
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1 The notice shall advise the enrollee of the rights
2 specified in this subsection.
3 If the managed care plan desires to have an attorney
4 present to represent its interests, it shall notify the
5 enrollee at least 14 days in advance of the review that an
6 attorney will be present and that the enrollee may wish to
7 obtain legal representation of his or her own.
8 Section 25. Grievance register and reporting
9 requirements.
10 (a) A managed care plan shall maintain a register
11 consisting of a written record of all complaints initiated
12 during the past 3 years. The register shall be maintained in
13 a manner that is reasonably clear and accessible to the
14 Director. The register shall include at a minimum the
15 following:
16 (1) the name of the enrollee;
17 (2) a description of the reason for the complaint;
18 (3) the dates when first level and second level
19 review were requested and completed;
20 (4) a copy of the written decision rendered at each
21 level of review;
22 (5) if required time limits were exceeded, an
23 explanation of why they were exceeded and a copy of the
24 enrollee's consent to an extension of time;
25 (6) whether expedited review was requested and the
26 response to the request;
27 (7) whether the complaint resulted in litigation
28 and the result of the litigation.
29 (b) A managed care plan shall report annually to the
30 Department the numbers, and related information where
31 indicated, for the following:
32 (1) covered lives;
33 (2) total complaints initiated;
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1 (3) total complaints involving medical necessity or
2 appropriateness;
3 (4) complaints involving termination or reduction
4 of inpatient hospital services;
5 (5) complaints involving termination or reduction
6 of other health care services;
7 (6) complaints involving denial of health care
8 services where the enrollee had not received the services
9 at the time the complaint was initiated;
10 (7) complaints involving payment for health care
11 services that the enrollee had already received at the
12 time of initiating the complaint;
13 (8) complaints resolved at each level of review and
14 how they were resolved;
15 (9) complaints where expedited review was provided
16 because adherence to regular time limits would have
17 jeopardized the enrollee's life, health, or ability to
18 regain maximum function; and
19 (10) complaints that resulted in litigation and the
20 outcome of the litigation.
21 The Department shall promulgate rules regarding the
22 format of the report, the timing of the report, and other
23 matters related to the report.
24 Section 30. External independent review.
25 (a) If an enrollee's or enrollee's designee's request
26 for a covered service or claim for a covered service is
27 denied under the grievance review under Section 20 because
28 the service is not viewed as medically necessary, the
29 enrollee may initiate an external independent review.
30 (b) Within 30 days after the enrollee receives written
31 notice of such an adverse decision made under the second
32 level grievance review procedures of Section 20, if the
33 enrollee decides to initiate an external independent review,
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1 the enrollee shall send to the managed care plan a written
2 request for an external independent review, including any
3 material justification or documentation to support the
4 enrollee's request for the covered service or claim for a
5 covered service.
6 (c) Within 30 days after the managed care plan receives
7 a request for an external independent review from an
8 enrollee, the managed care plan shall:
9 (1) provide a mechanism for jointly selecting an
10 external independent reviewer by the enrollee, primary
11 care physician, and managed care plan; and
12 (2) forward to the independent reviewer all medical
13 records and supporting documentation pertaining to the
14 case, a summary description of the applicable issues
15 including a statement of the managed care plan's
16 decision, and the criteria used and the clinical reasons
17 for that decision.
18 (d) Within 5 days of receipt of all necessary
19 information, the independent reviewer or reviewers shall
20 evaluate and analyze the case and render a decision that is
21 based on whether or not the service or claim for the service
22 is medically necessary. The decision by the independent
23 reviewer or reviewers is final.
24 (e) Pursuant to subsection (c) of this Section, an
25 external independent reviewer shall:
26 (1) have no direct financial interest in or
27 connection to the case;
28 (2) be State licensed physicians, who are board
29 certified or board eligible by the appropriate American
30 Medical Specialty Board, if applicable, and who are in
31 the same or similar scope of practice as a physician who
32 typically manages the medical condition, procedure, or
33 treatment under review; and
34 (3) have not been informed of the specific identity
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1 of the enrollee or the enrollee's treating provider.
2 (f) If an appropriate reviewer pursuant to subsection
3 (e) of this Section for a particular case is not on the list
4 established by the Director, the parties shall choose a
5 reviewer who is mutually acceptable.
6 Section 35. Independent reviewers.
7 (a) From information filed with the Director on or
8 before March 1 of each year, the Director shall compile a
9 list of external independent reviewers and organizations that
10 represent external independent reviewers from lists provided
11 by managed care plans and by any State and county public
12 health department and State medical associations that wish to
13 submit a list to the Director. The Director may consult with
14 other persons about the suitability of any reviewer or any
15 potential reviewer. The Director shall annually review the
16 list and add and remove names as appropriate. On or before
17 June 1 of each year, the Director shall publish the list in
18 the Illinois Register.
19 (b) The managed care plan shall be solely responsible
20 for paying the fees of the external independent reviewer who
21 is selected to perform the review.
22 (c) An external independent reviewer who acts in good
23 faith shall have immunity from any civil or criminal
24 liability or professional discipline as a result of acts or
25 omissions with respect to any external independent review,
26 unless the acts or omissions constitute wilful and wanton
27 misconduct. For purposes of any proceeding, the good faith
28 of the person participating shall be presumed.
29 (d) The Director's decision to add a name to or remove a
30 name from the list of independent reviewers pursuant to
31 subsection (a) is not subject to administrative appeal or
32 judicial review.