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| Public Act 099-0537 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Health Carrier External Review Act is | ||||
amended by changing Section 65 as follows: | ||||
(215 ILCS 180/65)
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Sec. 65. External review reporting requirements. | ||||
(a) Each health carrier shall maintain written records in | ||||
the aggregate, by state, and for each type of health benefit | ||||
plan offered by the health carrier on all requests for external | ||||
review that the health carrier received notice from the | ||||
Director for each calendar year and submit a report to the | ||||
Director in the format specified by the Director by June 1 | ||||
March 1 of each year. | ||||
(a-5) An independent review organization assigned pursuant | ||||
to this Act to conduct an external review shall maintain | ||||
written records in the aggregate by state and by health carrier | ||||
on all requests for external review for which it conducted an | ||||
external review during a calendar year and submit a report in | ||||
the format specified by the Director by March 1 of each year. | ||||
(a-10) The report required by subsection (a-5) shall | ||||
include in the aggregate by state, and for each health carrier: | ||||
(1) the total number of requests for external review; | ||||
(2) the number of requests for external review resolved | ||
and, of those resolved, the number resolved upholding the | ||
adverse determination or final adverse determination and | ||
the number resolved reversing the adverse determination or | ||
final adverse determination; | ||
(3) the average length of time for resolution; | ||
(4) a summary of the types of coverages or cases for | ||
which an external review was sought, as provided in the | ||
format required by the Director; | ||
(5) the number of external reviews that were terminated | ||
as the result of a reconsideration by the health carrier of | ||
its adverse determination or final adverse determination | ||
after the receipt of additional information from the | ||
covered person or the covered person's authorized | ||
representative; and | ||
(6) any other information the Director may request or | ||
require. | ||
(a-15) The independent review organization shall retain | ||
the written records required pursuant to this Section for at | ||
least 3 years. | ||
(b) The report required under subsection (a) of this | ||
Section shall include in the aggregate, by state, and by type | ||
of health benefit plan:
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(1) the total number of requests for external review; | ||
(2) the total number of requests for expedited external | ||
review;
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(3) the total number of requests for external review | ||
denied; | ||
(4) the number of requests for external review | ||
resolved, including: | ||
(A) the number of requests for external review | ||
resolved upholding the adverse determination or final | ||
adverse determination; | ||
(B) the number of requests for external review | ||
resolved reversing the adverse determination or final | ||
adverse determination; | ||
(C) the number of requests for expedited external | ||
review resolved upholding the adverse determination or | ||
final adverse determination; and | ||
(D) the number of requests for expedited external | ||
review resolved reversing the adverse determination or | ||
final adverse determination; | ||
(5) the average length of time for resolution for an | ||
external review; | ||
(6) the average length of time for resolution for an | ||
expedited external review; | ||
(7) a summary of the types of coverages or cases for | ||
which an external review was sought, as specified below:
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(A) denial of care or treatment (dissatisfaction | ||
regarding prospective non-authorization of a request | ||
for care or treatment recommended by a provider | ||
excluding diagnostic procedures and referral requests; | ||
partial approvals and care terminations are also | ||
considered to be denials); | ||
(B) denial of diagnostic procedure | ||
(dissatisfaction regarding prospective | ||
non-authorization of a request for a diagnostic | ||
procedure recommended by a provider; partial approvals | ||
are also considered to be denials); | ||
(C) denial of referral request (dissatisfaction | ||
regarding non-authorization of a request for a | ||
referral to another provider recommended by a PCP); | ||
(D) claims and utilization review (dissatisfaction | ||
regarding the concurrent or retrospective evaluation | ||
of the coverage, medical necessity, efficiency or | ||
appropriateness of health care services or treatment | ||
plans; prospective "Denials of care or treatment", | ||
"Denials of diagnostic procedures" and "Denials of | ||
referral requests" should not be classified in this | ||
category, but the appropriate one above);
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(8) the number of external reviews that were terminated | ||
as the result of a reconsideration by the health carrier of | ||
its adverse determination or final adverse determination | ||
after the receipt of additional information from the | ||
covered person or the covered person's authorized | ||
representative; and | ||
(9) any other information the Director may request or | ||
require.
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(Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.)
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Section 99. Effective date. This Act takes effect January | ||
1, 2017.
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