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Coventry Health Care of Illinois, Inc. ("Coventry Health Care") is One of Illinois' Highest Ranked Health Plans
Coventry Health Care is one of the top-ranked commercial health plans in Illinois for the fifth consecutive year, and ranked 27 out of more than 200 commercial health plans nationwide, according to a November 2010 publication by Consumer Reports and NCQA.
2016 Central Illinois Small Group Certificates of Coverage (COC)
To obtain the terms of your policy or a copy of your plan document, select the appropriate product group from the list below and click on the link.
The Certificate of Coverage gives you helpful information about what the plan covers. These are sample documents for your information only. Plan terms including cost sharing may vary from your actual coverage based on the plan and state selected. If the document(s) you are searching for is not listed below, then it is pending state approval. The document(s) will be available on this page at a later date upon state approval.
Carelink St. John's PPO
Understanding How to Get the Right Health Care
To get the most out of your health care benefits, it is important to know what a PCP is and what they do for you. It's also important to know when you should go to an Urgent Care Center versus the Emergency Department. We created a brochure to help you better understand the basics of getting the right care at the right place.
Complaints and Appeals
Complaint and appeal policies are in place to ensure that we have effective procedures for addressing, documenting, and resolving complaints or appeals.
The complaint procedure gives a member the right to express dissatisfaction with any aspect of the organization and to request review of any matter related to:
- The quality of health care service received
- General inquiries about covered services
- Member rights and responsibilities
You may call Customer Service at the number on the back of your Member ID card if you would like to file a complaint with Coventry Health Care.
If you are not pleased with a coverage decision that Coventry Health Care made, you may file an appeal. The appeals procedures give members the opportunity to ask us to review any matter related to:
- Issues about the scope of coverage for health care services
- Medical necessity of services requested
- Denial of care/services/claim
- Other adverse benefit determinations
Appeal requests should be sent in writing to: Coventry Health Care, Attn: Appeals Department, 2110 Fox Drive, Suite A, Champaign, IL 61820-7399. Urgent appeal requests may be made verbally to Customer Service. An urgent or expedited appeal occurs when a quick decision is necessary because a member's health is at risk. For expedited appeals, we advise the member within 24 hours what information is needed; allow the member 48 hours to provide that information; and provide a decision within 24 hours from the time we receive the information. For all other appeals, we provide decision within 15 business days after we receive the information needed to evaluate the appeal.
If our decision involved making a judgment as to the medical necessity, the service is considered Experimental/Investigational, Pre-existing, or your coverage is being rescinded (voided) for any reason other than non-payment of premiums and contributions, you have the right to have our decision reviewed by an independent review organization ("IRO") not associated with us by contacting the Illinois Department of Insurance, Office of Consumer Health Insurance, 320 W. Washington Street, Springfield, IL 62767; (phone) 877-850-4747 (Toll-Free); (fax) 217-557-8495 or at http://Insurance.Illinois.gov/ExternalReview for a standard or expedited external review. You may also contact the Office of Consumer Health Insurance (OCHI), Illinois Department of Insurance, 320 West Washington Street, Springfield, IL 62767-0001, 877-527-9431 (Toll-Free).
External Review (PDF)
Financial Compensation – Doctors Make the Decisions
Coventry Health Care uses a process called utilization management (UM) to review the care provided to our members. Our policy is to make decisions based on proven medical science. There are no financial incentives in the review process.
Important facts to know about our UM decisions:
- We use clinical decision tools and standards. Care and/or service must be medically necessary and delivered at the right site of care. Decisions also take into account your benefit plan and coverage.
- Decision making is based only on appropriateness of care and service and existence of coverage.
- Coventry Health Care does not reward practitioners or other individuals for denying coverage.
- Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
How We Evaluate New Technology
Doctors and health care manufacturers are constantly developing new technologies. They can include anything from a new way to perform a procedure to a new use for a piece of equipment. So Coventry Health Care, Inc. established a system to review and evaluate new technologies.
When a new technology is presented to Coventry, we do a thorough review of existing literature. The opinion of experts in the field may be requested. They may also contact the accrediting body of the appropriate medical specialty.
Coventry compares the information against established criteria. Then we decide whether to provide coverage. All of our decisions are based on making sure you have the appropriate care and services. We continue to focus on providing our members with quality health care products.
Your Privacy Matters
Coventry Health Care works hard to keep your personal and health information secure and private.
We need information about you to manage your benefits. We collect your information from many sources. And keeping your information safe is one of our most important jobs. We make sure that only people who need to use your information have access to it. We may use and share your information for:
- Health care operations
These uses are covered under state and federal laws. Our policies will reflect the most protective laws that apply to you.
Member Rights and Responsibilities
To ensure that our members are treated fairly, we have provided a list of member rights and responsibilities below. We encourage you to become familiar with them.
Your Quality of Care
Coventry Health Care’s quality improvement (QI) program works to ensure that all of our services meet high standards of quality and safety.
How to Read Your Forms
Balance Billing Reporting Information
Illinois Department of Insurance - File a complaint
Illinois Inspector General - Report provider fraud
My Online Services
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