Record of complaints

Record of complaints. (a) The Department shall maintain records concerning the complaints filed against health care plans. To that end, the Department shall require health care plans to annually report complaints made to and resolutions by health care plans in a manner determined by rule. The Department shall make a summary of all data collected available upon request and publish the summary on the World Wide Web. (b) The Department shall maintain records on the number of complaints filed against each health care plan. (c) The Department shall maintain records classifying each complaint by whether the complaint was filed by: (1) a consumer or enrollee; (2) a provider; or (3) any other individual. (d) The Department shall maintain records classifying each complaint according to the nature of the complaint as it pertains to a specific function of the health care plan. The complaints shall be classified under the following categories: (1) denial of care or treatment; (2) denial of a diagnostic procedure; (3) denial of a referral request; (4) sufficient choice and accessibility of health care providers; (5) underwriting; (6) marketing and sales; (7) claims and utilization review; (8) member services; (9) provider relations; and (10) miscellaneous. (e) The Department shall maintain records classifying the disposition of each complaint. The disposition of the complaint shall be classified in one of the following categories: (1) complaint referred to the health care plan and no further action necessary by the Department; (2) no corrective action deemed necessary by the Department; or (3) corrective action taken by the Department. (f) No Department publication or release of information shall identify any enrollee, health care provider, or individual complainant. (Source: P.A. 91-617, eff. 1-1-00.)