Section 4530.40 Health Carrier Obligations

Section 4530.40  Health Carrier Obligations

a)         Each

health carrier shall maintain written records in the aggregate, by state, and

for each type of health benefit plan offered by the health carrier on all

requests for external review for which the health carrier received notice from

the Director for each calendar year. The health carrier shall submit, electronically,

a report to the Director, in the format specified by the Director, by June 1 of

each year.

b)         A health carrier must

file with the Director for approval sample copies of:

1)         All

notices and forms that carriers must provide to covered persons under Sections

20, 25, 35, 40 and 42 of the Act.  In addition to those statutory requirements,

the following information must be included on notices sent to members in

response to member appeals:

A)        All

notices and forms must prominently display the name, address, toll-free phone

number, fax number and appeal email address of the carrier or administrator

that handles appeals;

B)        All

notices and forms shall be specific and limited to information regarding

appeals and external review procedures for the member's plan;

C)        All

notices shall state the number of levels of appeals available (no more than two

levels for group and one level for individual) under the plan and will state

which level of appeal is applicable to the adverse determination within the

notice;

D)        All

notices shall include the date, including month, day and year, of the adverse

determination and, if applicable, the date of the final adverse determination,

including month, day and year;

E)        All

notices shall inform covered persons that the deadlines for filing an appeal or

external review request are not postponed or delayed by health care provider

appeals unless the health care provider is acting as an authorized

representative for the covered person; i.e., the covered person should be

filing internal appeals independently and concurrently unless the health care

pro

E)        All

notices shall inform covered persons that the deadlines for filing an appeal or

external review request are not postponed or delayed by health care provider

appeals unless the health care provider is acting as an authorized

representative for the covered person; i.e., the covered person should be

filing internal appeals independently and concurrently unless the health care

provider has been designated in writing as the authorized representative;

F)         All

notices shall indicate whether the adverse determination relates to a member

appeal (filed by the member or authorized representative who may be the health

care provider) or a provider appeal (pursuant to the provider contract) and

shall explain timeframes from the date of the adverse determination for the

member to appeal and to file an external review regardless of the status of a

provider appeal;

G)        Upon

exhaustion of provider appeals, the notice (which is copied to the member)

shall specify timeframes from the date of the final adverse determination for

the member to file an appeal or file an external review;

H)        Upon

exhaustion of internal appeals by the member, the final adverse determination

notice shall clearly state that it is the final adverse determination, that all

internal appeals have been exhausted, and that the member has 4 months from the

date of the letter to file an external review;

I)         All

notices shall include the following contact information for the Department of

Insurance:

Illinois Departments of Insurance

Office of Consumer Health

Insurance

External Review Unit

320 W. Washington Street

Springfield IL 62767

Toll-free Telephone: (877)

850-4740

Fax: (217) 557-8495

Email:

doi.externalreview@illinois.gov

Website: https://mc.insurance.illinois.gov/messagecenter.nsf

2)         Descriptions

for both the required standard external review and expedited external review

procedures as set forth within Section 20 of the Act

r Health

Insurance

External Review Unit

320 W. Washington Street

Springfield IL 62767

Toll-free Telephone: (877)

850-4740

Fax: (217) 557-8495

Email:

doi.externalreview@illinois.gov

Website: https://mc.insurance.illinois.gov/messagecenter.nsf

2)         Descriptions

for both the required standard external review and expedited external review

procedures as set forth within Section 20 of the Act.

3)         Statements

informing the covered person and any authorized representative that a standard

external review request deemed to be ineligible for review by the plan or its

representative may be appealed to the Director by filing a complaint with the

Director.  The health carrier shall use the following address and provide the

following contact information when directing the covered person or authorized

representative to appeal initial determinations of ineligibility for standard

external review:

The Illinois Department of

Insurance

Office of Consumer Health

Insurance

External Review Unit

320 West Washington Street

Springfield IL  62767

Toll-free Telephone:  (877)

527-9431

Fax: (217) 557-8495

Email:

doi.externalreview@illinois.gov

Website: https://mc.insurance.illinois.gov/messagecenter.nsf

4)         Statements

informing the covered person and any authorized representative that an

expedited external review request deemed to be ineligible for review by the

plan or its representative may be appealed to the Director by filing a

complaint with the Director

7-9431

Fax: (217) 557-8495

Email:

doi.externalreview@illinois.gov

Website: https://mc.insurance.illinois.gov/messagecenter.nsf

4)         Statements

informing the covered person and any authorized representative that an

expedited external review request deemed to be ineligible for review by the

plan or its representative may be appealed to the Director by filing a

complaint with the Director.  The health carrier shall use the following

address when directing the covered person or authorized representative to

appeal initial determinations of ineligibility for expedited external review:

The Illinois Department of

Insurance

Office of Consumer Health

Insurance

External Review Unit

320 West Washington Street

Springfield IL  62767

Toll-free Telephone: (877)

850-4740

Fax: (217) 557-8495

Email:

doi.externalreview@illinois.gov

Website:  https://mc.insurance.illinois.gov/messagecenter.nsf

5)         Special

Rules for Multi-State Plans Under the Marketplace

Pursuant to the U.S. Office of

Personnel Management's (OPM) Multi‑State Plan Program regulation at 45

CFR 800.5023, OPM administers the External Review Process for disputed adverse

benefit determinations submitted by enrollees in Multi-State Plan health

insurance options.