January 2020

Quality of Care Complaints

Quality of Care (QOC) complaints submitted by our members most commonly express dissatisfaction with one or more of the following circumstances regarding their medical care: clinical issues, access to care issues, interpersonal issues and/or service issues.

When a QOC complaint is received from a member, Blue Cross and Blue Shield of Illinois (BCBSIL) reviews the complaint to determine next steps. QOC complaints may require follow-up with all involved parties to help support our members’ safety and/or alert providers whose actions may have contributed in some way to our members’ dissatisfaction.

If follow-up with the provider is deemed necessary, a letter is sent to the provider requesting a response, which may include a request from BCBSIL for medical records to aid in our investigation of the complaint. The member’s Application for Coverage and Membership Certificate Agreement authorizes the release of required documents for this purpose. Therefore, a separate authorization for release of records is not necessary to ensure compliance with the request.

We seek to identify and evaluate individual instances of where there may be a potential QOC issue or concern. Quality review of individual cases may result in interventions such as corrective action, termination, or other action depending on case-specific details and findings of the review.

If you have questions about how member QOC complaints are handled and/or your responsibilities as a provider, please contact your Provider Network Consultant (PNC) team for help.