Joint Resolution of Complaints – Department of Insurance and Department of Public Health - Notification and Resolution Process

Section 5420 Section 4520.80  Joint Resolution of Complaints – Department of Insurance and Department of Public Health − Notification and Resolution Process a)         Complaints against health care plans participating in programs administered by the Department of Healthcare and Family Services (HFS) pursuant to the Public Aid Code shall be resolved under rules published by HFS.  Any complaints against such plans received by the Department of Insurance or the Department of Public Health shall be referred to HFS. b)         Any enrollee or health care provider, on behalf of the enrollee, may file a written complaint against the health care plan through the Department of Insurance.  Complaints received by the Department of Public Health shall be referred to the Department of Insurance for processing prior to investigation. c)         The health care plan response shall include documentation and an explanation of all actions taken or not taken that were the basis for the complaint.  The respondent shall include documents necessary to support the respondent's position and any additional information requested by the Department of Insurance and/or the Department of Public Health.  Both the Department of Insurance and the Department of Public Health shall maintain confidentiality of medical records and other pertinent documents. d)         Quality of care complaints may be referred to the Department of Public Health for investigation. 1)         The Department of Public Health shall determine if an on-site investigation is warranted and may request additional information from the complainant, health care provider, or health care plan if the information provided is determined to be incomplete or if additional information is needed to make a determination regarding the complaint. 2)         If an investigation is warranted, the Department of Public Health shall make available the name, address and telephone number where an enrollee may obtain the status of the complaint. 3)         The Department of Public Health shall forward the findings of the investigation to the Department for final disposition and record keeping. e)         No Department of Insurance or Department of Public Health publication or release of information shall identify any enrollee, health care provider, or individual complainant.