Public Act 096-0967
 
HB5079 Enrolled LRB096 18956 RPM 34344 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Health Carrier External Review Act is
amended by changing Section 35 as follows:
 
    (215 ILCS 180/35)
    (This Section may contain text from a Public Act with a
delayed effective date)
    Sec. 35. Standard external review.
    (a) Within 4 months after the date of receipt of a notice
of an adverse determination or final adverse determination, a
covered person or the covered person's authorized
representative may file a request for an external review with
the health carrier.
    (b) Within 5 business days following the date of receipt of
the external review request, the health carrier shall complete
a preliminary review of the request to determine whether:
        (1) the individual is or was a covered person in the
    health benefit plan at the time the health care service was
    requested or at the time the health care service was
    provided;
        (2) the health care service that is the subject of the
    adverse determination or the final adverse determination
    is a covered service under the covered person's health
    benefit plan, but the health carrier has determined that
    the health care service is not covered because it does not
    meet the health carrier's requirements for medical
    necessity, appropriateness, health care setting, level of
    care, or effectiveness;
        (3) the covered person has exhausted the health
    carrier's internal grievance process as set forth in this
    Act;
        (4) for appeals relating to a determination based on
    treatment being experimental or investigational, the
    requested health care service or treatment that is the
    subject of the adverse determination or final adverse
    determination is a covered benefit under the covered
    person's health benefit plan except for the health
    carrier's determination that the service or treatment is
    experimental or investigational for a particular medical
    condition and is not explicitly listed as an excluded
    benefit under the covered person's health benefit plan with
    the health carrier and that the covered person's health
    care provider, who ordered or provided the services in
    question and who is licensed under the Medical Practice Act
    of 1987 is a physician licensed to practice medicine in all
    its branches, has certified that one of the following
    situations is applicable:
            (A) standard health care services or treatments
        have not been effective in improving the condition of
        the covered person;
            (B) standard health care services or treatments
        are not medically appropriate for the covered person;
            (C) there is no available standard health care
        service or treatment covered by the health carrier that
        is more beneficial than the recommended or requested
        health care service or treatment;
            (D) the health care service or treatment is likely
        to be more beneficial to the covered person, in the
        health care provider's opinion, than any available
        standard health care services or treatments; or
            (E) that scientifically valid studies using
        accepted protocols demonstrate that the health care
        service or treatment requested is likely to be more
        beneficial to the covered person than any available
        standard health care services or treatments; and
        (5) the covered person has provided all the information
    and forms required to process an external review, as
    specified in this Act.
    (c) Within one business day after completion of the
preliminary review, the health carrier shall notify the covered
person and, if applicable, the covered person's authorized
representative in writing whether the request is complete and
eligible for external review. If the request:
        (1) is not complete, the health carrier shall inform
    the covered person and, if applicable, the covered person's
    authorized representative in writing and include in the
    notice what information or materials are required by this
    Act to make the request complete; or
        (2) is not eligible for external review, the health
    carrier shall inform the covered person and, if applicable,
    the covered person's authorized representative in writing
    and include in the notice the reasons for its
    ineligibility.
    The notice of initial determination of ineligibility shall
include a statement informing the covered person and, if
applicable, the covered person's authorized representative
that a health carrier's initial determination that the external
review request is ineligible for review may be appealed to the
Director by filing a complaint with the Director.
    Notwithstanding a health carrier's initial determination
that the request is ineligible for external review, the
Director may determine that a request is eligible for external
review and require that it be referred for external review. In
making such determination, the Director's decision shall be in
accordance with the terms of the covered person's health
benefit plan and shall be subject to all applicable provisions
of this Act.
    (d) Whenever a request is eligible for external review the
health carrier shall, within 5 business days:
        (1) assign an independent review organization from the
    list of approved independent review organizations compiled
    and maintained by the Director; and
        (2) notify in writing the covered person and, if
    applicable, the covered person's authorized representative
    of the request's eligibility and acceptance for external
    review and the name of the independent review organization.
    The health carrier shall include in the notice provided to
the covered person and, if applicable, the covered person's
authorized representative a statement that the covered person
or the covered person's authorized representative may, within 5
business days following the date of receipt of the notice
provided pursuant to item (2) of this subsection (d), submit in
writing to the assigned independent review organization
additional information that the independent review
organization shall consider when conducting the external
review. The independent review organization is not required to,
but may, accept and consider additional information submitted
after 5 business days.
    (e) The assignment of an approved independent review
organization to conduct an external review in accordance with
this Section shall be made from those approved independent
review organizations qualified to conduct external review as
required by Sections 50 and 55 of this Act.
    (f) Upon assignment of an independent review organization,
the health carrier or its designee utilization review
organization shall, within 5 business days, provide to the
assigned independent review organization the documents and any
information considered in making the adverse determination or
final adverse determination; in such cases, the following
provisions shall apply:
        (1) Except as provided in item (2) of this subsection
    (f), failure by the health carrier or its utilization
    review organization to provide the documents and
    information within the specified time frame shall not delay
    the conduct of the external review.
        (2) If the health carrier or its utilization review
    organization fails to provide the documents and
    information within the specified time frame, the assigned
    independent review organization may terminate the external
    review and make a decision to reverse the adverse
    determination or final adverse determination.
        (3) Within one business day after making the decision
    to terminate the external review and make a decision to
    reverse the adverse determination or final adverse
    determination under item (2) of this subsection (f), the
    independent review organization shall notify the health
    carrier, the covered person and, if applicable, the covered
    person's authorized representative, of its decision to
    reverse the adverse determination.
    (g) Upon receipt of the information from the health carrier
or its utilization review organization, the assigned
independent review organization shall review all of the
information and documents and any other information submitted
in writing to the independent review organization by the
covered person and the covered person's authorized
representative.
    (h) Upon receipt of any information submitted by the
covered person or the covered person's authorized
representative, the independent review organization shall
forward the information to the health carrier within 1 business
day.
        (1) Upon receipt of the information, if any, the health
    carrier may reconsider its adverse determination or final
    adverse determination that is the subject of the external
    review.
        (2) Reconsideration by the health carrier of its
    adverse determination or final adverse determination shall
    not delay or terminate the external review.
        (3) The external review may only be terminated if the
    health carrier decides, upon completion of its
    reconsideration, to reverse its adverse determination or
    final adverse determination and provide coverage or
    payment for the health care service that is the subject of
    the adverse determination or final adverse determination.
    In such cases, the following provisions shall apply:
            (A) Within one business day after making the
        decision to reverse its adverse determination or final
        adverse determination, the health carrier shall notify
        the covered person and if applicable, the covered
        person's authorized representative, and the assigned
        independent review organization in writing of its
        decision.
            (B) Upon notice from the health carrier that the
        health carrier has made a decision to reverse its
        adverse determination or final adverse determination,
        the assigned independent review organization shall
        terminate the external review.
    (i) In addition to the documents and information provided
by the health carrier or its utilization review organization
and the covered person and the covered person's authorized
representative, if any, the independent review organization,
to the extent the information or documents are available and
the independent review organization considers them
appropriate, shall consider the following in reaching a
decision:
        (1) the covered person's pertinent medical records;
        (2) the covered person's health care provider's
    recommendation;
        (3) consulting reports from appropriate health care
    providers and other documents submitted by the health
    carrier, the covered person, the covered person's
    authorized representative, or the covered person's
    treating provider;
        (4) the terms of coverage under the covered person's
    health benefit plan with the health carrier to ensure that
    the independent review organization's decision is not
    contrary to the terms of coverage under the covered
    person's health benefit plan with the health carrier;
        (5) the most appropriate practice guidelines, which
    shall include applicable evidence-based standards and may
    include any other practice guidelines developed by the
    federal government, national or professional medical
    societies, boards, and associations;
        (6) any applicable clinical review criteria developed
    and used by the health carrier or its designee utilization
    review organization; and
        (7) the opinion of the independent review
    organization's clinical reviewer or reviewers after
    considering items (1) through (6) of this subsection (i) to
    the extent the information or documents are available and
    the clinical reviewer or reviewers considers the
    information or documents appropriate; and
        (8) for a denial of coverage based on a determination
    that the health care service or treatment recommended or
    requested is experimental or investigational, whether and
    to what extent:
            (A) the recommended or requested health care
        service or treatment has been approved by the federal
        Food and Drug Administration, if applicable, for the
        condition;
            (B) medical or scientific evidence or
        evidence-based standards demonstrate that the expected
        benefits of the recommended or requested health care
        service or treatment is more likely than not to be
        beneficial to the covered person than any available
        standard health care service or treatment and the
        adverse risks of the recommended or requested health
        care service or treatment would not be substantially
        increased over those of available standard health care
        services or treatments; or
            (C) the terms of coverage under the covered
        person's health benefit plan with the health carrier to
        ensure that the health care service or treatment that
        is the subject of the opinion is experimental or
        investigational would otherwise be covered under the
        terms of coverage of the covered person's health
        benefit plan with the health carrier.
    (j) Within 5 days after the date of receipt of all
necessary information, the assigned independent review
organization shall provide written notice of its decision to
uphold or reverse the adverse determination or the final
adverse determination to the health carrier, the covered person
and, if applicable, the covered person's authorized
representative. In reaching a decision, the assigned
independent review organization is not bound by any claim
determinations reached prior to the submission of information
to the independent review organization. In such cases, the
following provisions shall apply:
        (1) The independent review organization shall include
    in the notice:
            (A) a general description of the reason for the
        request for external review;
            (B) the date the independent review organization
        received the assignment from the health carrier to
        conduct the external review;
            (C) the time period during which the external
        review was conducted;
            (D) references to the evidence or documentation,
        including the evidence-based standards, considered in
        reaching its decision;
            (E) the date of its decision; and
            (F) the principal reason or reasons for its
        decision, including what applicable, if any,
        evidence-based standards that were a basis for its
        decision.
        (2) For reviews of experimental or investigational
    treatments, the notice shall include the following
    information:
            (A) a description of the covered person's medical
        condition;
            (B) a description of the indicators relevant to
        whether there is sufficient evidence to demonstrate
        that the recommended or requested health care service
        or treatment is more likely than not to be more
        beneficial to the covered person than any available
        standard health care services or treatments and the
        adverse risks of the recommended or requested health
        care service or treatment would not be substantially
        increased over those of available standard health care
        services or treatments;
            (C) a description and analysis of any medical or
        scientific evidence considered in reaching the
        opinion;
            (D) a description and analysis of any
        evidence-based standards;
            (E) whether the recommended or requested health
        care service or treatment has been approved by the
        federal Food and Drug Administration, for the
        condition;
            (F) whether medical or scientific evidence or
        evidence-based standards demonstrate that the expected
        benefits of the recommended or requested health care
        service or treatment is more likely than not to be more
        beneficial to the covered person than any available
        standard health care service or treatment and the
        adverse risks of the recommended or requested health
        care service or treatment would not be substantially
        increased over those of available standard health care
        services or treatments; and
            (G) the written opinion of the clinical reviewer,
        including the reviewer's recommendation as to whether
        the recommended or requested health care service or
        treatment should be covered and the rationale for the
        reviewer's recommendation.
        (3) In reaching a decision, the assigned independent
    review organization is not bound by any decisions or
    conclusions reached during the health carrier's
    utilization review process or the health carrier's
    internal grievance or appeals process.
        (4) Upon receipt of a notice of a decision reversing
    the adverse determination or final adverse determination,
    the health carrier immediately shall approve the coverage
    that was the subject of the adverse determination or final
    adverse determination.
(Source: P.A. 96-857, eff. 7-1-10.)
 
    Section 95. No acceleration or delay. Where this Act makes
changes in a statute that is represented in this Act by text
that is not yet or no longer in effect (for example, a Section
represented by multiple versions), the use of that text does
not accelerate or delay the taking effect of (i) the changes
made by this Act or (ii) provisions derived from any other
Public Act.