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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 1. Short title. This Act may be cited as the Health | ||||||
5 | Carrier External Review Act. | ||||||
6 | Section 5. Purpose and intent. The purpose of this Act is | ||||||
7 | to provide uniform standards for the establishment and | ||||||
8 | maintenance of external review procedures to assure that | ||||||
9 | covered persons have the opportunity for an independent review | ||||||
10 | of an adverse determination or final adverse determination, as | ||||||
11 | defined in this Act. | ||||||
12 | Section 10. Definitions. For the purposes of this Act: | ||||||
13 | "Adverse determination" means a determination by a health | ||||||
14 | carrier or its designee utilization review organization that an | ||||||
15 | admission, availability of care, continued stay, or other | ||||||
16 | health care service that is a covered benefit has been reviewed | ||||||
17 | and, based upon the information provided, does not meet the | ||||||
18 | health carrier's requirements for medical necessity, | ||||||
19 | appropriateness, health care setting, level of care, or | ||||||
20 | effectiveness, and the requested service or payment for the | ||||||
21 | service is therefore denied, reduced, or terminated. | ||||||
22 | "Authorized representative" means: |
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1 | (1) a person to whom a covered person has given express | ||||||
2 | written consent to represent the covered person in an | ||||||
3 | external review, including the covered person's health | ||||||
4 | care provider; | ||||||
5 | (2) a person authorized by law to provide substituted | ||||||
6 | consent for a covered person; or | ||||||
7 | (3) the covered person's health care provider when the | ||||||
8 | covered person is unable to provide consent. | ||||||
9 | "Best evidence" means evidence based on: | ||||||
10 | (1) randomized clinical trials; | ||||||
11 | (2) if randomized clinical trials are not available, | ||||||
12 | then cohort studies or case-control studies; | ||||||
13 | (3) if items (1) and (2) are not available, then | ||||||
14 | case-series; or | ||||||
15 | (4) if items (1), (2), and (3) are not available, then | ||||||
16 | expert opinion. | ||||||
17 | "Case-series" means an evaluation of a series of patients | ||||||
18 | with a particular outcome, without the use of a control group. | ||||||
19 | "Clinical review criteria" means the written screening | ||||||
20 | procedures, decision abstracts, clinical protocols, and | ||||||
21 | practice guidelines used by a health carrier to determine the | ||||||
22 | necessity and appropriateness of health care services. | ||||||
23 | "Cohort study" means a prospective evaluation of 2 groups | ||||||
24 | of patients with only one group of patients receiving specific | ||||||
25 | intervention. | ||||||
26 | "Covered benefits" or "benefits" means those health care |
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1 | services to which a covered person is entitled under the terms | ||||||
2 | of a health benefit plan. | ||||||
3 | "Covered person" means a policyholder, subscriber, | ||||||
4 | enrollee, or other individual participating in a health benefit | ||||||
5 | plan. | ||||||
6 | "Director" means the Director of the Department of | ||||||
7 | Insurance. | ||||||
8 | "Emergency medical condition" means a medical condition | ||||||
9 | manifesting itself by acute symptoms of sufficient severity, | ||||||
10 | including, but not limited to, severe pain, such that a prudent | ||||||
11 | layperson who possesses an average knowledge of health and | ||||||
12 | medicine could reasonably expect the absence of immediate | ||||||
13 | medical attention to result in: | ||||||
14 | (1) placing the health of the individual or, with | ||||||
15 | respect to a pregnant woman, the health of the woman or her | ||||||
16 | unborn child, in serious jeopardy; | ||||||
17 | (2) serious impairment to bodily functions; or
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18 | (3) serious dysfunction of any bodily organ or part. | ||||||
19 | "Emergency services" means health care items and services | ||||||
20 | furnished or required to evaluate and treat an emergency | ||||||
21 | medical condition. | ||||||
22 | "Evidence-based standard" means the conscientious, | ||||||
23 | explicit, and judicious use of the current best evidence based | ||||||
24 | on an overall systematic review of the research in making | ||||||
25 | decisions about the care of individual patients. | ||||||
26 | "Expert opinion" means a belief or an interpretation by |
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1 | specialists with experience in a specific area about the | ||||||
2 | scientific evidence pertaining to a particular service, | ||||||
3 | intervention, or therapy. | ||||||
4 | "Facility" means an institution providing health care | ||||||
5 | services or a health care setting. | ||||||
6 | "Final adverse determination" means an adverse | ||||||
7 | determination involving a covered benefit that has been upheld | ||||||
8 | by a health carrier, or its designee utilization review | ||||||
9 | organization, at the completion of the health carrier's | ||||||
10 | internal grievance process procedures as set forth by the | ||||||
11 | Managed Care Reform and Patient Rights Act. | ||||||
12 | "Health benefit plan" means a policy, contract, | ||||||
13 | certificate, plan, or agreement offered or issued by a health | ||||||
14 | carrier to provide, deliver, arrange for, pay for, or reimburse | ||||||
15 | any of the costs of health care services. | ||||||
16 | "Health care provider" or "provider" means a physician, | ||||||
17 | hospital facility, or other health care practitioner licensed, | ||||||
18 | accredited, or certified to perform specified health care | ||||||
19 | services consistent with State law, responsible for | ||||||
20 | recommending health care services on behalf of a covered | ||||||
21 | person. | ||||||
22 | "Health care services" means services for the diagnosis, | ||||||
23 | prevention, treatment, cure, or relief of a health condition, | ||||||
24 | illness, injury, or disease. | ||||||
25 | "Health carrier" means an entity subject to the insurance | ||||||
26 | laws and regulations of this State, or subject to the |
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1 | jurisdiction of the Director, that contracts or offers to | ||||||
2 | contract to provide, deliver, arrange for, pay for, or | ||||||
3 | reimburse any of the costs of health care services, including a | ||||||
4 | sickness and accident insurance company, a health maintenance | ||||||
5 | organization, or any other entity providing a plan of health | ||||||
6 | insurance, health benefits, or health care services. "Health | ||||||
7 | carrier" also means Limited Health Service Organizations | ||||||
8 | (LHSO) and Voluntary Health Service Plans. | ||||||
9 | "Health information" means information or data, whether | ||||||
10 | oral or recorded in any form or medium, and personal facts or | ||||||
11 | information about events or relationships that relate to:
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12 | (1) the past, present, or future physical, mental, or | ||||||
13 | behavioral health or condition of an individual or a member | ||||||
14 | of the individual's family; | ||||||
15 | (2) the provision of health care services to an | ||||||
16 | individual; or | ||||||
17 | (3) payment for the provision of health care services | ||||||
18 | to an individual. | ||||||
19 | "Independent review organization" means an entity that | ||||||
20 | conducts independent external reviews of adverse | ||||||
21 | determinations and final adverse determinations. | ||||||
22 | "Medical or scientific evidence" means evidence found in | ||||||
23 | the following sources: | ||||||
24 | (1) peer-reviewed scientific studies published in or | ||||||
25 | accepted for publication by medical journals that meet | ||||||
26 | nationally recognized requirements for scientific |
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1 | manuscripts and that submit most of their published | ||||||
2 | articles for review by experts who are not part of the | ||||||
3 | editorial staff; | ||||||
4 | (2) peer-reviewed medical literature, including | ||||||
5 | literature relating to therapies reviewed and approved by a | ||||||
6 | qualified institutional review board, biomedical | ||||||
7 | compendia, and other medical literature that meet the | ||||||
8 | criteria of the National Institutes of Health's Library of | ||||||
9 | Medicine for indexing in Index Medicus (Medline) and | ||||||
10 | Elsevier Science Ltd. for indexing in Excerpta Medicus | ||||||
11 | (EMBASE); | ||||||
12 | (3) medical journals recognized by the Secretary of | ||||||
13 | Health and Human Services under Section 1861(t)(2) of the | ||||||
14 | federal Social Security Act; | ||||||
15 | (4) the following standard reference compendia:
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16 | (a) The American Hospital Formulary Service-Drug | ||||||
17 | Information; | ||||||
18 | (b) Drug Facts and Comparisons; | ||||||
19 | (c) The American Dental Association Accepted | ||||||
20 | Dental Therapeutics; and | ||||||
21 | (d) The United States Pharmacopoeia-Drug | ||||||
22 | Information; | ||||||
23 | (5) findings, studies, or research conducted by or | ||||||
24 | under the auspices of federal government agencies and | ||||||
25 | nationally recognized federal research institutes, | ||||||
26 | including: |
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1 | (a) the federal Agency for Healthcare Research and | ||||||
2 | Quality; | ||||||
3 | (b) the National Institutes of Health; | ||||||
4 | (c) the National Cancer Institute; | ||||||
5 | (d) the National Academy of Sciences; | ||||||
6 | (e) the Centers for Medicare & Medicaid Services; | ||||||
7 | (f) the federal Food and Drug Administration; and | ||||||
8 | (g) any national board recognized by the National | ||||||
9 | Institutes of Health for the purpose of evaluating the | ||||||
10 | medical value of health care services; or | ||||||
11 | (6) any other medical or scientific evidence that is | ||||||
12 | comparable to the sources listed in items (1) through (5). | ||||||
13 | "Protected health information" means health information | ||||||
14 | (i) that identifies an individual who is the subject of the | ||||||
15 | information; or (ii) with respect to which there is a | ||||||
16 | reasonable basis to believe that the information could be used | ||||||
17 | to identify an individual. | ||||||
18 | "Retrospective review" means a review of medical necessity | ||||||
19 | conducted after services have been provided to a patient, but | ||||||
20 | does not include the review of a claim that is limited to an | ||||||
21 | evaluation of reimbursement levels, veracity of documentation, | ||||||
22 | accuracy of coding, or adjudication for payment. | ||||||
23 | "Utilization review" has the meaning provided by the | ||||||
24 | Managed Care Reform and Patient Rights Act. | ||||||
25 | "Utilization review organization" means a utilization | ||||||
26 | review program as defined in the Managed Care Reform and |
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1 | Patient Rights Act. | ||||||
2 | Section 15. Applicability and scope. | ||||||
3 | (a) Except as provided in subsection (b) of this Section, | ||||||
4 | this Act shall apply to all health carriers. | ||||||
5 | (b) The provisions of this Act shall not apply to a policy | ||||||
6 | or certificate that provides coverage only for a specified | ||||||
7 | disease, specified accident or accident-only coverage, credit, | ||||||
8 | dental, disability income, hospital indemnity, long-term care | ||||||
9 | insurance as defined by Article XIXA of the Illinois Insurance | ||||||
10 | Code, vision care, or any other limited supplemental benefit; a | ||||||
11 | Medicare supplement policy of insurance as defined by the | ||||||
12 | Director by regulation; coverage under a plan through Medicare, | ||||||
13 | Medicaid, or the federal employees health benefits program; any | ||||||
14 | coverage issued under Chapter 55 of Title 10, U.S. Code and any | ||||||
15 | coverage issued as supplement to that coverage; any coverage | ||||||
16 | issued as supplemental to liability insurance, workers' | ||||||
17 | compensation, or similar insurance; automobile medical-payment | ||||||
18 | insurance or any insurance under which benefits are payable | ||||||
19 | with or without regard to fault, whether written on a group | ||||||
20 | blanket or individual basis. | ||||||
21 | Section 20. Notice of right to external review. | ||||||
22 | (a) At the same time the health carrier sends written | ||||||
23 | notice of a covered person's right to appeal a coverage | ||||||
24 | decision upon an adverse determination or a final adverse |
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1 | determination as provided by the Managed Care Reform and | ||||||
2 | Patient Rights Act, a health carrier shall notify a covered | ||||||
3 | person and a covered person's health care provider in writing | ||||||
4 | of the covered person's right to request an external review as | ||||||
5 | provided by this Act. The written notice required shall include | ||||||
6 | the following, or substantially equivalent, language: "We have | ||||||
7 | denied your request for the provision of or payment for a | ||||||
8 | health care service or course of treatment. You have the right | ||||||
9 | to have our decision reviewed by an independent review | ||||||
10 | organization not associated with us if our decision involved | ||||||
11 | making a judgment as to the medical necessity, appropriateness, | ||||||
12 | health care setting, level of care, or effectiveness of the | ||||||
13 | health care service or treatment you requested by submitting a | ||||||
14 | written request for an external review to us. Upon receipt of | ||||||
15 | your request an independent review organization registered | ||||||
16 | with the Department of Insurance will be assigned to review our | ||||||
17 | decision. | ||||||
18 | (b) This subsection (b) shall apply to an expedited review | ||||||
19 | prior to a final adverse determination. In addition to the | ||||||
20 | notice required in subsection (a), the health carrier shall | ||||||
21 | include a notice related to an adverse determination, a | ||||||
22 | statement informing the covered person all of the following: | ||||||
23 | (1) If the covered person has a medical condition where | ||||||
24 | the timeframe for completion of (A) an expedited internal | ||||||
25 | review of a grievance involving an adverse determination, | ||||||
26 | (B) a final adverse determination as set forth in the |
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1 | Managed Care Reform and Patient Rights Act, or (C) a | ||||||
2 | standard external review as established in this Act, would | ||||||
3 | seriously jeopardize the life or health of the covered | ||||||
4 | person or would jeopardize the covered person's ability to | ||||||
5 | regain maximum function, then the covered person or the | ||||||
6 | covered person's authorized representative may file a | ||||||
7 | request for an expedited external review. | ||||||
8 | (2) The covered person or the covered person's | ||||||
9 | authorized representative may file a request for an | ||||||
10 | expedited external review at the same time the covered | ||||||
11 | person or the covered person's authorized representative | ||||||
12 | files a request for an expedited internal appeal involving | ||||||
13 | an adverse determination as set forth in the Managed Care | ||||||
14 | Reform and Patient Rights Act if the adverse determination | ||||||
15 | involves a denial of coverage based on a determination that | ||||||
16 | the recommended or requested health care service or | ||||||
17 | treatment is experimental or investigational and the | ||||||
18 | covered person's health care provider certifies in writing | ||||||
19 | that the recommended or requested health care service or | ||||||
20 | treatment that is the subject of the adverse determination | ||||||
21 | would be significantly less effective if not promptly | ||||||
22 | initiated. The independent review organization assigned to | ||||||
23 | conduct the expedited external review will determine | ||||||
24 | whether the covered person shall be required to complete | ||||||
25 | the expedited review of the grievance prior to conducting | ||||||
26 | the expedited external review. |
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1 | (3) If an adverse determination concerns a denial of | ||||||
2 | coverage based on a determination that the recommended or | ||||||
3 | requested health care service or treatment is experimental | ||||||
4 | or investigational and the covered person's health care | ||||||
5 | provider certifies in writing that the recommended or | ||||||
6 | requested health care service or treatment that is the | ||||||
7 | subject of the request would be significantly less | ||||||
8 | effective if not promptly initiated, then the covered | ||||||
9 | person or the covered person's authorized representative | ||||||
10 | may request an expedited external review. | ||||||
11 | (c) This subsection (c) shall apply to an expedited review | ||||||
12 | upon final adverse determination. In addition to the notice | ||||||
13 | required in subsection (a), the health carrier shall include a | ||||||
14 | notice related to a final adverse determination, a statement | ||||||
15 | informing the covered person all of the following: | ||||||
16 | (1) if the covered person has a medical condition where | ||||||
17 | the timeframe for completion of a standard external review | ||||||
18 | would seriously jeopardize the life or health of the | ||||||
19 | covered person or would jeopardize the covered person's | ||||||
20 | ability to regain maximum function, then the covered person | ||||||
21 | or the covered person's authorized representative may file | ||||||
22 | a request for an expedited external review; or | ||||||
23 | (2) if a final adverse determination concerns an | ||||||
24 | admission, availability of care, continued stay, or health | ||||||
25 | care service for which the covered person received | ||||||
26 | emergency services, but has not been discharged from a |
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1 | facility, then the covered person, or the covered person's | ||||||
2 | authorized representative, may request an expedited | ||||||
3 | external review; or | ||||||
4 | (3) if a final adverse determination concerns a denial | ||||||
5 | of coverage based on a determination that the recommended | ||||||
6 | or requested health care service or treatment is | ||||||
7 | experimental or investigational, and the covered person's | ||||||
8 | health care provider certifies in writing that the | ||||||
9 | recommended or requested health care service or treatment | ||||||
10 | that is the subject of the request would be significantly | ||||||
11 | less effective if not promptly initiated, then the covered | ||||||
12 | person or the covered person's authorized representative | ||||||
13 | may request an expedited external review. | ||||||
14 | (d) In addition to the information to be provided pursuant | ||||||
15 | to subsections (a), (b), and (c) of this Section, the health | ||||||
16 | carrier shall include a copy of the description of both the | ||||||
17 | required standard and expedited external review procedures. | ||||||
18 | The description shall highlight the external review procedures | ||||||
19 | that give the covered person or the covered person's authorized | ||||||
20 | representative the opportunity to submit additional | ||||||
21 | information, including any forms used to process an external | ||||||
22 | review. | ||||||
23 | Section 25. Request for external review. A covered person | ||||||
24 | or the covered person's authorized representative may make a | ||||||
25 | request for a standard external or expedited external review of |
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1 | an adverse determination or final adverse determination. | ||||||
2 | Requests under this Section shall be made directly to the | ||||||
3 | health carrier that made the adverse or final adverse | ||||||
4 | determination. All requests for external review shall be in | ||||||
5 | writing except for requests for expedited external reviews | ||||||
6 | which may me made orally. Health carriers must provide covered | ||||||
7 | persons with forms to request external reviews. | ||||||
8 | Section 30. Exhaustion of internal grievance process. | ||||||
9 | Except as provided in subsection (b) of Section 20, a | ||||||
10 | request for an external review shall not be made until the | ||||||
11 | covered person has exhausted the health carrier's internal | ||||||
12 | grievance process as set forth in the Managed Care Reform and | ||||||
13 | Patient Rights Act. A covered person shall also be considered | ||||||
14 | to have exhausted the health carrier's internal grievance | ||||||
15 | process for purposes of this Section if: | ||||||
16 | (1) the covered person or the covered person's | ||||||
17 | authorized representative filed a request for an internal | ||||||
18 | review of an adverse determination pursuant to the Managed | ||||||
19 | Care Reform and Patient Rights Act and has not received a | ||||||
20 | written decision on the request from the health carrier | ||||||
21 | within 15 days after receipt of the required information | ||||||
22 | but not more than 30 days after the request was filed by | ||||||
23 | the covered person or the covered person's authorized | ||||||
24 | representative, except to the extent the covered person or | ||||||
25 | the covered person's authorized representative requested |
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1 | or agreed to a delay; however, a covered person or the | ||||||
2 | covered person's authorized representative may not make a | ||||||
3 | request for an external review of an adverse determination | ||||||
4 | involving a retrospective review determination until the | ||||||
5 | covered person has exhausted the health carrier's internal | ||||||
6 | grievance process; | ||||||
7 | (2) the covered person or the covered person's | ||||||
8 | authorized representative filed a request for an expedited | ||||||
9 | internal review of an adverse determination pursuant to the | ||||||
10 | Managed Care Reform and Patient Rights Act and has not | ||||||
11 | received a decision on request from the health carrier | ||||||
12 | within 48 hours, except to the extent the covered person or | ||||||
13 | the covered person's authorized representative requested | ||||||
14 | or agreed to a delay; or | ||||||
15 | (3) the health carrier agrees to waive the exhaustion | ||||||
16 | requirement. | ||||||
17 | Section 35. Standard external review. | ||||||
18 | (a) Within 4 months after the date of receipt of a notice | ||||||
19 | of an adverse determination or final adverse determination, a | ||||||
20 | covered person or the covered person's authorized | ||||||
21 | representative may file a request for an external review with | ||||||
22 | the health carrier. | ||||||
23 | (b) Within 5 business days following the date of receipt of | ||||||
24 | the external review request, the health carrier shall complete | ||||||
25 | a preliminary review of the request to determine whether:
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1 | (1) the individual is or was a covered person in the | ||||||
2 | health benefit plan at the time the health care service was | ||||||
3 | requested or at the time the health care service was | ||||||
4 | provided; | ||||||
5 | (2) the health care service that is the subject of the | ||||||
6 | adverse determination or the final adverse determination | ||||||
7 | is a covered service under the covered person's health | ||||||
8 | benefit plan, but the health carrier has determined that | ||||||
9 | the health care service is not covered because it does not | ||||||
10 | meet the health carrier's requirements for medical | ||||||
11 | necessity, appropriateness, health care setting, level of | ||||||
12 | care, or effectiveness; | ||||||
13 | (3) the covered person has exhausted the health | ||||||
14 | carrier's internal grievance process as set forth in this | ||||||
15 | Act; | ||||||
16 | (4) for appeals relating to a determination based on | ||||||
17 | treatment being experimental or investigational, the | ||||||
18 | requested health care service or treatment that is the | ||||||
19 | subject of the adverse determination or final adverse | ||||||
20 | determination is a covered benefit under the covered | ||||||
21 | person's health benefit plan except for the health | ||||||
22 | carrier's determination that the service or treatment is | ||||||
23 | experimental or investigational for a particular medical | ||||||
24 | condition and is not explicitly listed as an excluded | ||||||
25 | benefit under the covered person's health benefit plan with | ||||||
26 | the health carrier and that the covered person's health |
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1 | care provider, who is a physician licensed to practice | ||||||
2 | medicine in all its branches, has certified that one of the | ||||||
3 | following situations is applicable: | ||||||
4 | (A) standard health care services or treatments | ||||||
5 | have not been effective in improving the condition of | ||||||
6 | the covered person; | ||||||
7 | (B) standard health care services or treatments | ||||||
8 | are not medically appropriate for the covered person; | ||||||
9 | (C) there is no available standard health care | ||||||
10 | service or treatment covered by the health carrier that | ||||||
11 | is more beneficial than the recommended or requested | ||||||
12 | health care service or treatment;
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13 | (D) the health care service or treatment is likely | ||||||
14 | to be more beneficial to the covered person, in the | ||||||
15 | health care provider's opinion, than any available | ||||||
16 | standard health care services or treatments; or | ||||||
17 | (E) that scientifically valid studies using | ||||||
18 | accepted protocols demonstrate that the health care | ||||||
19 | service or treatment requested is likely to be more | ||||||
20 | beneficial to the covered person than any available | ||||||
21 | standard health care services or treatments; and | ||||||
22 | (5) the covered person has provided all the information | ||||||
23 | and forms required to process an external review, as | ||||||
24 | specified in this Act. | ||||||
25 | (c) Within one business day after completion of the | ||||||
26 | preliminary review, the health carrier shall notify the covered |
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1 | person and, if applicable, the covered person's authorized | ||||||
2 | representative in writing whether the request is complete and | ||||||
3 | eligible for external review. If the request: | ||||||
4 | (1) is not complete, the health carrier shall inform | ||||||
5 | the covered person and, if applicable, the covered person's | ||||||
6 | authorized representative in writing and include in the | ||||||
7 | notice what information or materials are required by this | ||||||
8 | Act to make the request complete; or | ||||||
9 | (2) is not eligible for external review, the health | ||||||
10 | carrier shall inform the covered person and, if applicable, | ||||||
11 | the covered person's authorized representative in writing | ||||||
12 | and include in the notice the reasons for its | ||||||
13 | ineligibility.
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14 | The notice of initial determination of ineligibility shall | ||||||
15 | include a statement informing the covered person and, if | ||||||
16 | applicable, the covered person's authorized representative | ||||||
17 | that a health carrier's initial determination that the external | ||||||
18 | review request is ineligible for review may be appealed to the | ||||||
19 | Director by filing a complaint with the Director. | ||||||
20 | Notwithstanding a health carrier's initial determination | ||||||
21 | that the request is ineligible for external review, the | ||||||
22 | Director may determine that a request is eligible for external | ||||||
23 | review and require that it be referred for external review. In | ||||||
24 | making such determination, the Director's decision shall be in | ||||||
25 | accordance with the terms of the covered person's health | ||||||
26 | benefit plan and shall be subject to all applicable provisions |
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1 | of this Act. | ||||||
2 | (d) Whenever a request is eligible for external review the | ||||||
3 | health carrier shall, within 5 business days: | ||||||
4 | (1) assign an independent review organization from the | ||||||
5 | list of approved independent review organizations compiled | ||||||
6 | and maintained by the Director; and | ||||||
7 | (2) notify in writing the covered person and, if | ||||||
8 | applicable, the covered person's authorized representative | ||||||
9 | of the request's eligibility and acceptance for external | ||||||
10 | review and the name of the independent review organization. | ||||||
11 | The health carrier shall include in the notice provided to | ||||||
12 | the covered person and, if applicable, the covered person's | ||||||
13 | authorized representative a statement that the covered person | ||||||
14 | or the covered person's authorized representative may, within 5 | ||||||
15 | business days following the date of receipt of the notice | ||||||
16 | provided pursuant to item (2) of this subsection (d), submit in | ||||||
17 | writing to the assigned independent review organization | ||||||
18 | additional information that the independent review | ||||||
19 | organization shall consider when conducting the external | ||||||
20 | review. The independent review organization is not required to, | ||||||
21 | but may, accept and consider additional information submitted | ||||||
22 | after 5 business days. | ||||||
23 | (e) The assignment of an approved independent review | ||||||
24 | organization to conduct an external review in accordance with | ||||||
25 | this Section shall be made from those approved independent | ||||||
26 | review organizations qualified to conduct external review as |
| |||||||
| |||||||
1 | required by Sections 50 and 55 of this Act. | ||||||
2 | (f) Upon assignment of an independent review organization, | ||||||
3 | the health carrier or its designee utilization review | ||||||
4 | organization shall, within 5 business days, provide to the | ||||||
5 | assigned independent review organization the documents and any | ||||||
6 | information considered in making the adverse determination or | ||||||
7 | final adverse determination; in such cases, the following | ||||||
8 | provisions shall apply: | ||||||
9 | (1) Except as provided in item (2) of this subsection | ||||||
10 | (f), failure by the health carrier or its utilization | ||||||
11 | review organization to provide the documents and | ||||||
12 | information within the specified time frame shall not delay | ||||||
13 | the conduct of the external review. | ||||||
14 | (2) If the health carrier or its utilization review | ||||||
15 | organization fails to provide the documents and | ||||||
16 | information within the specified time frame, the assigned | ||||||
17 | independent review organization may terminate the external | ||||||
18 | review and make a decision to reverse the adverse | ||||||
19 | determination or final adverse determination. | ||||||
20 | (3) Within one business day after making the decision | ||||||
21 | to terminate the external review and make a decision to | ||||||
22 | reverse the adverse determination or final adverse | ||||||
23 | determination under item (2) of this subsection (f), the | ||||||
24 | independent review organization shall notify the health | ||||||
25 | carrier, the covered person and, if applicable, the covered | ||||||
26 | person's authorized representative, of its decision to |
| |||||||
| |||||||
1 | reverse the adverse determination. | ||||||
2 | (g) Upon receipt of the information from the health carrier | ||||||
3 | or its utilization review organization, the assigned | ||||||
4 | independent review organization shall review all of the | ||||||
5 | information and documents and any other information submitted | ||||||
6 | in writing to the independent review organization by the | ||||||
7 | covered person and the covered person's authorized | ||||||
8 | representative. | ||||||
9 | (h) Upon receipt of any information submitted by the | ||||||
10 | covered person or the covered person's authorized | ||||||
11 | representative, the independent review organization shall | ||||||
12 | forward the information to the health carrier within 1 business | ||||||
13 | day. | ||||||
14 | (1) Upon receipt of the information, if any, the health | ||||||
15 | carrier may reconsider its adverse determination or final | ||||||
16 | adverse determination that is the subject of the external | ||||||
17 | review.
| ||||||
18 | (2) Reconsideration by the health carrier of its | ||||||
19 | adverse determination or final adverse determination shall | ||||||
20 | not delay or terminate the external review.
| ||||||
21 | (3) The external review may only be terminated if the | ||||||
22 | health carrier decides, upon completion of its | ||||||
23 | reconsideration, to reverse its adverse determination or | ||||||
24 | final adverse determination and provide coverage or | ||||||
25 | payment for the health care service that is the subject of | ||||||
26 | the adverse determination or final adverse determination. |
| |||||||
| |||||||
1 | In such cases, the following provisions shall apply: | ||||||
2 | (A) Within one business day after making the | ||||||
3 | decision to reverse its adverse determination or final | ||||||
4 | adverse determination, the health carrier shall notify | ||||||
5 | the covered person and if applicable, the covered | ||||||
6 | person's authorized representative, and the assigned | ||||||
7 | independent review organization in writing of its | ||||||
8 | decision. | ||||||
9 | (B) Upon notice from the health carrier that the | ||||||
10 | health carrier has made a decision to reverse its | ||||||
11 | adverse determination or final adverse determination, | ||||||
12 | the assigned independent review organization shall | ||||||
13 | terminate the external review. | ||||||
14 | (i) In addition to the documents and information provided | ||||||
15 | by the health carrier or its utilization review organization | ||||||
16 | and the covered person and the covered person's authorized | ||||||
17 | representative, if any, the independent review organization, | ||||||
18 | to the extent the information or documents are available and | ||||||
19 | the independent review organization considers them | ||||||
20 | appropriate, shall consider the following in reaching a | ||||||
21 | decision: | ||||||
22 | (1) the covered person's pertinent medical records; | ||||||
23 | (2) the covered person's health care provider's | ||||||
24 | recommendation; | ||||||
25 | (3) consulting reports from appropriate health care | ||||||
26 | providers and other documents submitted by the health |
| |||||||
| |||||||
1 | carrier, the covered person, the covered person's | ||||||
2 | authorized representative, or the covered person's | ||||||
3 | treating provider; | ||||||
4 | (4) the terms of coverage under the covered person's | ||||||
5 | health benefit plan with the health carrier to ensure that | ||||||
6 | the independent review organization's decision is not | ||||||
7 | contrary to the terms of coverage under the covered | ||||||
8 | person's health benefit plan with the health carrier; | ||||||
9 | (5) the most appropriate practice guidelines, which | ||||||
10 | shall include applicable evidence-based standards and may | ||||||
11 | include any other practice guidelines developed by the | ||||||
12 | federal government, national or professional medical | ||||||
13 | societies, boards, and associations; | ||||||
14 | (6) any applicable clinical review criteria developed | ||||||
15 | and used by the health carrier or its designee utilization | ||||||
16 | review organization; and | ||||||
17 | (7) the opinion of the independent review | ||||||
18 | organization's clinical reviewer or reviewers after | ||||||
19 | considering items (1) through (6) of this subsection (i) to | ||||||
20 | the extent the information or documents are available and | ||||||
21 | the clinical reviewer or reviewers considers the | ||||||
22 | information or documents appropriate; and | ||||||
23 | (8) for a denial of coverage based on a determination | ||||||
24 | that the health care service or treatment recommended or | ||||||
25 | requested is experimental or investigational, whether and | ||||||
26 | to what extent: |
| |||||||
| |||||||
1 | (A) the recommended or requested health care | ||||||
2 | service or treatment has been approved by the federal | ||||||
3 | Food and Drug Administration, if applicable, for the | ||||||
4 | condition; | ||||||
5 | (B) medical or scientific evidence or | ||||||
6 | evidence-based standards demonstrate that the expected | ||||||
7 | benefits of the recommended or requested health care | ||||||
8 | service or treatment is more likely than not to be | ||||||
9 | beneficial to the covered person than any available | ||||||
10 | standard health care service or treatment and the | ||||||
11 | adverse risks of the recommended or requested health | ||||||
12 | care service or treatment would not be substantially | ||||||
13 | increased over those of available standard health care | ||||||
14 | services or treatments; or | ||||||
15 | (C) the terms of coverage under the covered | ||||||
16 | person's health benefit plan with the health carrier to | ||||||
17 | ensure that the health care service or treatment that | ||||||
18 | is the subject of the opinion is experimental or | ||||||
19 | investigational would otherwise be covered under the | ||||||
20 | terms of coverage of the covered person's health | ||||||
21 | benefit plan with the health carrier. | ||||||
22 | (j) Within 5 days after the date of receipt of all | ||||||
23 | necessary information, the assigned independent review | ||||||
24 | organization shall provide written notice of its decision to | ||||||
25 | uphold or reverse the adverse determination or the final | ||||||
26 | adverse determination to the health carrier, the covered person |
| |||||||
| |||||||
1 | and, if applicable, the covered person's authorized | ||||||
2 | representative. In reaching a decision, the assigned | ||||||
3 | independent review organization is not bound by any claim | ||||||
4 | determinations reached prior to the submission of information | ||||||
5 | to the independent review organization. In such cases, the | ||||||
6 | following provisions shall apply: | ||||||
7 | (1) The independent review organization shall include | ||||||
8 | in the notice: | ||||||
9 | (A) a general description of the reason for the | ||||||
10 | request for external review; | ||||||
11 | (B) the date the independent review organization | ||||||
12 | received the assignment from the health carrier to | ||||||
13 | conduct the external review; | ||||||
14 | (C) the time period during which the external | ||||||
15 | review was conducted; | ||||||
16 | (D) references to the evidence or documentation, | ||||||
17 | including the evidence-based standards, considered in | ||||||
18 | reaching its decision; | ||||||
19 | (E) the date of its decision; and | ||||||
20 | (F) the principal reason or reasons for its | ||||||
21 | decision, including what applicable, if any, | ||||||
22 | evidence-based standards that were a basis for its | ||||||
23 | decision.
| ||||||
24 | (2) For reviews of experimental or investigational | ||||||
25 | treatments, the notice shall include the following | ||||||
26 | information: |
| |||||||
| |||||||
1 | (A) a description of the covered person's medical | ||||||
2 | condition; | ||||||
3 | (B) a description of the indicators relevant to | ||||||
4 | whether there is sufficient evidence to demonstrate | ||||||
5 | that the recommended or requested health care service | ||||||
6 | or treatment is more likely than not to be more | ||||||
7 | beneficial to the covered person than any available | ||||||
8 | standard health care services or treatments and the | ||||||
9 | adverse risks of the recommended or requested health | ||||||
10 | care service or treatment would not be substantially | ||||||
11 | increased over those of available standard health care | ||||||
12 | services or treatments; | ||||||
13 | (C) a description and analysis of any medical or | ||||||
14 | scientific evidence considered in reaching the | ||||||
15 | opinion; | ||||||
16 | (D) a description and analysis of any | ||||||
17 | evidence-based standards; | ||||||
18 | (E) whether the recommended or requested health | ||||||
19 | care service or treatment has been approved by the | ||||||
20 | federal Food and Drug Administration, for the | ||||||
21 | condition; | ||||||
22 | (F) whether medical or scientific evidence or | ||||||
23 | evidence-based standards demonstrate that the expected | ||||||
24 | benefits of the recommended or requested health care | ||||||
25 | service or treatment is more likely than not to be more | ||||||
26 | beneficial to the covered person than any available |
| |||||||
| |||||||
1 | standard health care service or treatment and the | ||||||
2 | adverse risks of the recommended or requested health | ||||||
3 | care service or treatment would not be substantially | ||||||
4 | increased over those of available standard health care | ||||||
5 | services or treatments; and | ||||||
6 | (G) the written opinion of the clinical reviewer, | ||||||
7 | including the reviewer's recommendation as to whether | ||||||
8 | the recommended or requested health care service or | ||||||
9 | treatment should be covered and the rationale for the | ||||||
10 | reviewer's recommendation. | ||||||
11 | (3) In reaching a decision, the assigned independent | ||||||
12 | review organization is not bound by any decisions or | ||||||
13 | conclusions reached during the health carrier's | ||||||
14 | utilization review process or the health carrier's | ||||||
15 | internal grievance or appeals process. | ||||||
16 | (4) Upon receipt of a notice of a decision reversing | ||||||
17 | the adverse determination or final adverse determination, | ||||||
18 | the health carrier immediately shall approve the coverage | ||||||
19 | that was the subject of the adverse determination or final | ||||||
20 | adverse determination. | ||||||
21 | Section 40. Expedited external review. | ||||||
22 | (a) A covered person or a covered person's authorized | ||||||
23 | representative may file a request for an expedited external | ||||||
24 | review with the health carrier either orally or in writing: | ||||||
25 | (1) immediately after the date of receipt of a notice |
| |||||||
| |||||||
1 | prior to a final adverse determination as provided by | ||||||
2 | subsection (b) of Section 20 of this Act; | ||||||
3 | (2) immediately after the date of receipt of a notice a | ||||||
4 | final adverse determination as provided by subsection (c) | ||||||
5 | of Section 20 of this Act; or | ||||||
6 | (3) if a health carrier fails to provide a decision on | ||||||
7 | request for an expedited internal appeal within 48 hours as | ||||||
8 | provided by item (2) of Section 30 of this Act. | ||||||
9 | (b) Immediately upon receipt of the request for an | ||||||
10 | expedited external review as provided under subsections (b) and | ||||||
11 | (c) of Section 20, the health carrier shall determine whether | ||||||
12 | the request meets the reviewability requirements set forth in | ||||||
13 | items (1), (2), and (4) of subsection (b) of Section 35. In | ||||||
14 | such cases, the following provisions shall apply: | ||||||
15 | (1) The health carrier shall immediately notify the | ||||||
16 | covered person and, if applicable, the covered person's | ||||||
17 | authorized representative of its eligibility | ||||||
18 | determination. | ||||||
19 | (2) The notice of initial determination shall include a | ||||||
20 | statement informing the covered person and, if applicable, | ||||||
21 | the covered person's authorized representative that a | ||||||
22 | health carrier's initial determination that an external | ||||||
23 | review request is ineligible for review may be appealed to | ||||||
24 | the Director. | ||||||
25 | (3) The Director may determine that a request is | ||||||
26 | eligible for expedited external review notwithstanding a |
| |||||||
| |||||||
1 | health carrier's initial determination that the request is | ||||||
2 | ineligible and require that it be referred for external | ||||||
3 | review. | ||||||
4 | (4) In making a determination under item (3) of this | ||||||
5 | subsection (b), the Director's decision shall be made in | ||||||
6 | accordance with the terms of the covered person's health | ||||||
7 | benefit plan and shall be subject to all applicable | ||||||
8 | provisions of this Act. | ||||||
9 | (c) Upon determining that a request meets the requirements | ||||||
10 | of subsections (b) and (c) of Section 20, the health
carrier | ||||||
11 | shall immediately assign an independent review organization | ||||||
12 | from the list of approved independent review organizations | ||||||
13 | compiled and maintained by the Director to conduct the | ||||||
14 | expedited review. In such cases, the following provisions shall | ||||||
15 | apply: | ||||||
16 | (1) The assignment of an approved independent review | ||||||
17 | organization to conduct an external review in accordance | ||||||
18 | with this Section shall be made from those approved | ||||||
19 | independent review organizations qualified to conduct | ||||||
20 | external review as required by Sections 50 and 55 of this | ||||||
21 | Act.
| ||||||
22 | (2) Immediately upon assigning an independent review | ||||||
23 | organization to perform an expedited external review, but | ||||||
24 | in no case more than 24 hours after assigning the | ||||||
25 | independent review organization, the health carrier or its | ||||||
26 | designee utilization review organization shall provide or |
| |||||||
| |||||||
1 | transmit all necessary documents and information | ||||||
2 | considered in making the final adverse determination to the | ||||||
3 | assigned independent review organization electronically or | ||||||
4 | by telephone or facsimile or any other available | ||||||
5 | expeditious method. | ||||||
6 | (3) If the health carrier or its utilization review | ||||||
7 | organization fails to provide the documents and | ||||||
8 | information within the specified timeframe, the assigned | ||||||
9 | independent review organization may terminate the external | ||||||
10 | review and make a decision to reverse the adverse | ||||||
11 | determination or final adverse determination. | ||||||
12 | (4) Within one business day after making the decision | ||||||
13 | to terminate the external review and make a decision to | ||||||
14 | reverse the adverse determination or final adverse | ||||||
15 | determination under item (3) of this subsection (c), the | ||||||
16 | independent review organization shall notify the health | ||||||
17 | carrier, the covered person and, if applicable, the covered | ||||||
18 | person's authorized representative of its decision to | ||||||
19 | reverse the adverse determination.
| ||||||
20 | (d) In addition to the documents and information provided | ||||||
21 | by the health carrier or its utilization review organization | ||||||
22 | and any documents and information provided by the covered | ||||||
23 | person and the covered person's authorized representative, the | ||||||
24 | independent review organization shall consider information as | ||||||
25 | required by subsection (i) of Section 35 of this Act in | ||||||
26 | reaching a decision. |
| |||||||
| |||||||
1 | (e) As expeditiously as the covered person's medical | ||||||
2 | condition or circumstances requires, but in no event more than | ||||||
3 | 2 business days after the receipt of all pertinent information, | ||||||
4 | the assigned independent review organization shall: | ||||||
5 | (1) make a decision to uphold or reverse the final | ||||||
6 | adverse determination; and | ||||||
7 | (2) notify the health carrier, the covered person, the | ||||||
8 | covered person's health care provider, and if applicable, | ||||||
9 | the covered person's authorized representative, of the | ||||||
10 | decision. | ||||||
11 | (f) In reaching a decision, the assigned independent review | ||||||
12 | organization is not bound by any decisions or conclusions | ||||||
13 | reached during the health carrier's utilization review process | ||||||
14 | or the health carrier's internal grievance process as set forth | ||||||
15 | in the Managed Care Reform and Patient Rights Act.
| ||||||
16 | (g) Upon receipt of notice of a decision reversing the | ||||||
17 | final adverse determination, the health carrier shall | ||||||
18 | immediately approve the coverage that was the subject of the | ||||||
19 | final adverse determination. | ||||||
20 | (h) Within 48 hours after the date of providing the notice | ||||||
21 | required in item (2) of subsection (e), the assigned | ||||||
22 | independent review organization shall provide written | ||||||
23 | confirmation of the decision to the health carrier, the covered | ||||||
24 | person, and if applicable, the covered person's authorized | ||||||
25 | representative including the information set forth in | ||||||
26 | subsection (j) of Section 35 of this Act as applicable. |
| |||||||
| |||||||
1 | (i) An expedited external review may not be provided for | ||||||
2 | retrospective adverse or final adverse determinations. | ||||||
3 | Section 45. Binding nature of external review decision. An | ||||||
4 | external review decision is binding on the health carrier. An | ||||||
5 | external review decision is binding on the covered person | ||||||
6 | except to the extent the covered person has other remedies | ||||||
7 | available under applicable federal or State law. A covered | ||||||
8 | person or the covered person's authorized representative may | ||||||
9 | not file a subsequent request for external review involving the | ||||||
10 | same adverse determination or final adverse determination for | ||||||
11 | which the covered person has already received an external | ||||||
12 | review decision pursuant to this Act.
| ||||||
13 | Section 50. Approval of independent review organizations. | ||||||
14 | (a) The Director shall approve independent review | ||||||
15 | organizations eligible to be assigned to conduct external | ||||||
16 | reviews under this Act. | ||||||
17 | (b) In order to be eligible for approval by the Director | ||||||
18 | under this Section to conduct external reviews under this Act | ||||||
19 | an independent review organization:
| ||||||
20 | (1) except as otherwise provided in this Section, shall | ||||||
21 | be accredited by a nationally recognized private | ||||||
22 | accrediting entity that the Director has determined has | ||||||
23 | independent review organization accreditation standards | ||||||
24 | that are equivalent to or exceed the minimum qualifications |
| |||||||
| |||||||
1 | for independent review; and | ||||||
2 | (2) shall submit an application for approval in | ||||||
3 | accordance with subsection (d) of this Section.
| ||||||
4 | (c) The Director shall develop an application form for | ||||||
5 | initially approving and for reapproving independent review | ||||||
6 | organizations to conduct external reviews. | ||||||
7 | (d) Any independent review organization wishing to be | ||||||
8 | approved to conduct external reviews under this Act shall | ||||||
9 | submit the application form and include with the form all | ||||||
10 | documentation and information necessary for the Director to | ||||||
11 | determine if the independent review organization satisfies the | ||||||
12 | minimum qualifications established under this Act.
The | ||||||
13 | Director may: | ||||||
14 | (1) approve independent review organizations that are | ||||||
15 | not accredited by a nationally recognized private | ||||||
16 | accrediting entity if there are no acceptable nationally | ||||||
17 | recognized private accrediting entities providing | ||||||
18 | independent review organization accreditation; and | ||||||
19 | (2) by rule establish an application fee that | ||||||
20 | independent review organizations shall submit to the | ||||||
21 | Director with an application for approval and renewing.
| ||||||
22 | (e) An approval is effective for 2 years, unless the | ||||||
23 | Director determines before its expiration that the independent | ||||||
24 | review organization is not satisfying the minimum | ||||||
25 | qualifications established under this Act. | ||||||
26 | (f) Whenever the Director determines that an independent |
| |||||||
| |||||||
1 | review organization has lost its accreditation or no longer | ||||||
2 | satisfies the minimum requirements established under this Act, | ||||||
3 | the Director shall terminate the approval of the independent | ||||||
4 | review organization and remove the independent review | ||||||
5 | organization from the list of independent review organizations | ||||||
6 | approved to conduct external reviews under this Act that is | ||||||
7 | maintained by the Director. | ||||||
8 | (g) The Director shall maintain and periodically update a | ||||||
9 | list of approved independent review organizations. | ||||||
10 | (h) The Director may promulgate regulations to carry out | ||||||
11 | the provisions of this Section. | ||||||
12 | Section 55. Minimum qualifications for independent review | ||||||
13 | organizations.
| ||||||
14 | (a) To be approved to conduct external reviews, an | ||||||
15 | independent review organization shall have and maintain | ||||||
16 | written policies and procedures that govern all aspects of both | ||||||
17 | the standard external review process and the expedited external | ||||||
18 | review process set forth in this Act that include, at a | ||||||
19 | minimum: | ||||||
20 | (1) a quality assurance mechanism that ensures that: | ||||||
21 | (A) external reviews are conducted within the | ||||||
22 | specified timeframes and required notices are provided | ||||||
23 | in a timely manner; | ||||||
24 | (B) selection of qualified and impartial clinical | ||||||
25 | reviewers to conduct external reviews on behalf of the |
| |||||||
| |||||||
1 | independent review organization and suitable matching | ||||||
2 | of reviewers to specific cases and that the independent | ||||||
3 | review organization employs or contracts with an | ||||||
4 | adequate number of clinical reviewers to meet this | ||||||
5 | objective; | ||||||
6 | (C) for adverse determinations involving | ||||||
7 | experimental or investigational treatments, in | ||||||
8 | assigning clinical reviewers, the independent review | ||||||
9 | organization selects physicians or other health care | ||||||
10 | professionals who, through clinical experience in the | ||||||
11 | past 3 years, are experts in the treatment of the | ||||||
12 | covered person's condition and knowledgeable about the | ||||||
13 | recommended or requested health care service or | ||||||
14 | treatment; | ||||||
15 | (D) the health carrier, the covered person, and the | ||||||
16 | covered person's authorized representative shall not | ||||||
17 | choose or control the choice of the physicians or other | ||||||
18 | health care professionals to be selected to conduct the | ||||||
19 | external review; | ||||||
20 | (E) confidentiality of medical and treatment | ||||||
21 | records and clinical review criteria; and | ||||||
22 | (F) any person employed by or under contract with | ||||||
23 | the independent review organization adheres to the | ||||||
24 | requirements of this Act; | ||||||
25 | (2) a toll-free telephone service operating on a | ||||||
26 | 24-hour-day, 7-day-a-week basis that accepts, receives, |
| |||||||
| |||||||
1 | and records information related to external reviews and | ||||||
2 | provides appropriate instructions; and | ||||||
3 | (3) an agreement to maintain and provide to the | ||||||
4 | Director the information set out in Section 70 of this Act. | ||||||
5 | (b) All clinical reviewers assigned by an independent | ||||||
6 | review organization to conduct external reviews shall be | ||||||
7 | physicians or other appropriate health care providers who meet | ||||||
8 | the following minimum qualifications:
| ||||||
9 | (1) be an expert in the treatment of the covered | ||||||
10 | person's medical condition that is the subject of the | ||||||
11 | external review; | ||||||
12 | (2) be knowledgeable about the recommended health care | ||||||
13 | service or treatment through recent or current actual | ||||||
14 | clinical experience treating patients with the same or | ||||||
15 | similar medical condition of the covered person; | ||||||
16 | (3) hold a non-restricted license in a state of the | ||||||
17 | United States and, for physicians, a current certification | ||||||
18 | by a recognized American medical specialty board in the | ||||||
19 | area or areas appropriate to the subject of the external | ||||||
20 | review; and | ||||||
21 | (4) have no history of disciplinary actions or | ||||||
22 | sanctions, including loss of staff privileges or | ||||||
23 | participation restrictions, that have been taken or are | ||||||
24 | pending by any hospital, governmental agency or unit, or | ||||||
25 | regulatory body that raise a substantial question as to the | ||||||
26 | clinical reviewer's physical, mental, or professional |
| |||||||
| |||||||
1 | competence or moral character. | ||||||
2 | (c) In addition to the requirements set forth in subsection | ||||||
3 | (a), an independent review organization may not own or control, | ||||||
4 | be a subsidiary of, or in any way be owned, or controlled by, | ||||||
5 | or exercise control with a health benefit plan, a national, | ||||||
6 | State, or local trade association of health benefit plans, or a | ||||||
7 | national, State, or local trade association of health care | ||||||
8 | providers. | ||||||
9 | (d) Conflicts of interest prohibited.
In addition to the | ||||||
10 | requirements set forth in subsections (a), (b), and (c) of this | ||||||
11 | Section, to be approved pursuant to this Act to conduct an | ||||||
12 | external review of a specified case, neither the independent | ||||||
13 | review organization selected to conduct the external review nor | ||||||
14 | any clinical reviewer assigned by the independent organization | ||||||
15 | to conduct the external review may have a material | ||||||
16 | professional, familial or financial conflict of interest with | ||||||
17 | any of the following: | ||||||
18 | (1) the health carrier that is the subject of the | ||||||
19 | external review; | ||||||
20 | (2) the covered person whose treatment is the subject | ||||||
21 | of the external review or the covered person's authorized | ||||||
22 | representative; | ||||||
23 | (3) any officer, director or management employee of the | ||||||
24 | health carrier that is the subject of the external review; | ||||||
25 | (4) the health care provider, the health care | ||||||
26 | provider's medical group or independent practice |
| |||||||
| |||||||
1 | association recommending the health care service or | ||||||
2 | treatment that is the subject of the external review; | ||||||
3 | (5) the facility at which the recommended health care | ||||||
4 | service or treatment would be provided; or | ||||||
5 | (6) the developer or manufacturer of the principal | ||||||
6 | drug, device, procedure, or other therapy being | ||||||
7 | recommended for the covered person whose treatment is the | ||||||
8 | subject of the external review.
| ||||||
9 | (e) An independent review organization that is accredited | ||||||
10 | by a nationally recognized private accrediting entity that has | ||||||
11 | independent review accreditation standards that the Director | ||||||
12 | has determined are equivalent to or exceed the minimum | ||||||
13 | qualifications of this Section shall be presumed to be in | ||||||
14 | compliance with this Section and shall be eligible for approval | ||||||
15 | under this Act. | ||||||
16 | (f) An independent review organization shall be unbiased. | ||||||
17 | An independent review organization shall establish and | ||||||
18 | maintain written procedures to ensure that it is unbiased in | ||||||
19 | addition to any other procedures required under this Section. | ||||||
20 | (g) Nothing in this Act precludes or shall be interpreted | ||||||
21 | to preclude a health carrier from contracting with approved | ||||||
22 | independent review organizations to conduct external reviews | ||||||
23 | assigned to it from such health carrier. | ||||||
24 | Section 60. Hold harmless for independent review | ||||||
25 | organizations. No independent review organization or clinical |
| |||||||
| |||||||
1 | reviewer working on behalf of an independent review | ||||||
2 | organization or an employee, agent or contractor of an | ||||||
3 | independent review organization shall be liable for damages to | ||||||
4 | any person for any opinions rendered or acts or omissions | ||||||
5 | performed within the scope of the organization's or person's | ||||||
6 | duties under the law during or upon completion of an external | ||||||
7 | review conducted pursuant to this Act, unless the opinion was | ||||||
8 | rendered or act or omission performed in bad faith or involved | ||||||
9 | gross negligence. | ||||||
10 | Section 65. External review reporting requirements. | ||||||
11 | (a) Each health carrier shall maintain written records in | ||||||
12 | the aggregate on all requests for external review for each | ||||||
13 | calendar year and submit a report to the Director in the format | ||||||
14 | specified by the Director by March 1 of each year. | ||||||
15 | (b) The report shall include in the aggregate:
| ||||||
16 | (1) the total number of requests for external review; | ||||||
17 | (2) the total number of requests for expedited external | ||||||
18 | review;
| ||||||
19 | (3) the total number of requests for external review | ||||||
20 | denied; | ||||||
21 | (4) the number of requests for external review | ||||||
22 | resolved, including: | ||||||
23 | (A) the number of requests for external review | ||||||
24 | resolved upholding the adverse determination or final | ||||||
25 | adverse determination; |
| |||||||
| |||||||
1 | (B) the number of requests for external review | ||||||
2 | resolved reversing the adverse determination or final | ||||||
3 | adverse determination; | ||||||
4 | (C) the number of requests for expedited external | ||||||
5 | review resolved upholding the adverse determination or | ||||||
6 | final adverse determination; and | ||||||
7 | (D) the number of requests for expedited external | ||||||
8 | review resolved reversing the adverse determination or | ||||||
9 | final adverse determination; | ||||||
10 | (5) the average length of time for resolution for an | ||||||
11 | external review; | ||||||
12 | (6) the average length of time for resolution for an | ||||||
13 | expedited external review; | ||||||
14 | (7) a summary of the types of coverages or cases for | ||||||
15 | which an external review was sought, as specified below:
| ||||||
16 | (A) denial of care or treatment (dissatisfaction | ||||||
17 | regarding prospective non-authorization of a request | ||||||
18 | for care or treatment recommended by a provider | ||||||
19 | excluding diagnostic procedures and referral requests; | ||||||
20 | partial approvals and care terminations are also | ||||||
21 | considered to be denials); | ||||||
22 | (B) denial of diagnostic procedure | ||||||
23 | (dissatisfaction regarding prospective | ||||||
24 | non-authorization of a request for a diagnostic | ||||||
25 | procedure recommended by a provider; partial approvals | ||||||
26 | are also considered to be denials); |
| |||||||
| |||||||
1 | (C) denial of referral request (dissatisfaction | ||||||
2 | regarding non-authorization of a request for a | ||||||
3 | referral to another provider recommended by a PCP); | ||||||
4 | (D) claims and utilization review (dissatisfaction | ||||||
5 | regarding the concurrent or retrospective evaluation | ||||||
6 | of the coverage, medical necessity, efficiency or | ||||||
7 | appropriateness of health care services or treatment | ||||||
8 | plans; prospective "Denials of care or treatment", | ||||||
9 | "Denials of diagnostic procedures" and "Denials of | ||||||
10 | referral requests" should not be classified in this | ||||||
11 | category, but the appropriate one above);
| ||||||
12 | (8) the number of external reviews that were terminated | ||||||
13 | as the result of a reconsideration by the health carrier of | ||||||
14 | its adverse determination or final adverse determination | ||||||
15 | after the receipt of additional information from the | ||||||
16 | covered person or the covered person's authorized | ||||||
17 | representative; and | ||||||
18 | (9) any other information the Director may request or | ||||||
19 | require.
| ||||||
20 | Section 70. Funding of external review. The health carrier | ||||||
21 | shall be solely responsible for paying the cost of external | ||||||
22 | reviews conducted by independent review organizations. | ||||||
23 | Section 75. Disclosure requirements. | ||||||
24 | (a) Each health carrier shall include a description of the |
| |||||||
| |||||||
1 | external review procedures in, or attached to, the policy, | ||||||
2 | certificate, membership booklet, and outline of coverage or | ||||||
3 | other evidence of coverage it provides to covered persons. | ||||||
4 | (b) The description required under subsection (a) of this | ||||||
5 | Section shall include a statement that informs the covered | ||||||
6 | person of the right of the covered person to file a request for | ||||||
7 | an external review of an adverse determination or final adverse | ||||||
8 | determination with the health carrier. The statement shall | ||||||
9 | explain that external review is available when the adverse | ||||||
10 | determination or final adverse determination involves an issue | ||||||
11 | of medical necessity, appropriateness, health care setting, | ||||||
12 | level of care, or effectiveness. The statement shall include | ||||||
13 | the toll-free telephone number and address of the Office of | ||||||
14 | Consumer Health Insurance within the Department of Insurance.
| ||||||
15 | Section 90. The Illinois Insurance Code is amended by | ||||||
16 | changing Section 155.36 and by adding Sections 359b and 359c as | ||||||
17 | follows:
| ||||||
18 | (215 ILCS 5/155.36)
| ||||||
19 | Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||||||
20 | Insurance
companies that transact the kinds of insurance | ||||||
21 | authorized under Class 1(b) or
Class 2(a) of Section 4 of this | ||||||
22 | Code shall comply
with Sections 45 and Section 85 and the | ||||||
23 | definition of the term "emergency medical
condition" in Section
| ||||||
24 | 10 of the Managed Care Reform and Patient Rights Act.
|
| |||||||
| |||||||
1 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
2 | (215 ILCS 5/359b new)
| ||||||
3 | Sec. 359b. Committee to create a uniform small employer | ||||||
4 | group-health status questionnaire and individual health | ||||||
5 | statement. | ||||||
6 | (a) For the purposes of this Section: | ||||||
7 | "Employee health-status questionnaire" means a | ||||||
8 | questionnaire that poses questions about an individual | ||||||
9 | employee's or covered dependent's health history and that is to | ||||||
10 | be completed by the individual employee or covered dependent of | ||||||
11 | a small employer that seeks health insurance coverage from a | ||||||
12 | small employer carrier. | ||||||
13 | "Health benefit plan", "small employer", and "small | ||||||
14 | employer carrier" shall have the meaning given the terms in the | ||||||
15 | Small Employer Health Insurance Rating Act. | ||||||
16 | "Individual health insurance coverage" and "individual | ||||||
17 | market" shall have the meaning given the terms in the Illinois | ||||||
18 | Health Insurance Portability and Accountability Act. | ||||||
19 | (b) A committee is established in the Department consisting | ||||||
20 | of 11 members, including the Director or the Director's | ||||||
21 | designee, who are appointed by the Director. The Director shall | ||||||
22 | appoint to the committee 5 representatives as recommended by | ||||||
23 | the Illinois Insurance Association, Illinois Life Insurance | ||||||
24 | Council, Professional Independent Insurance Agents of | ||||||
25 | Illinois, Illinois Association of Health Underwriters, |
| |||||||
| |||||||
1 | Illinois Chamber of Commerce, Illinois Manufacturers | ||||||
2 | Association, Illinois Retail Merchants Association, and | ||||||
3 | National Federation of Independent Businesses and 5 consumer | ||||||
4 | representatives. The Director or the Director's designee shall | ||||||
5 | serve as chairperson of the committee. | ||||||
6 | (c) The committee shall develop a uniform employee | ||||||
7 | health-status questionnaire to simplify the health insurance | ||||||
8 | application process for small employers. The committee shall | ||||||
9 | study employee-health status questionnaires currently used by | ||||||
10 | major small employer carriers in this State and consolidate the | ||||||
11 | questionnaires into a uniform questionnaire. The questionnaire | ||||||
12 | shall be designed to permit its use both as a written document | ||||||
13 | and through electronic or other alternative delivery formats. | ||||||
14 | A uniform employee health-status questionnaire shall allow | ||||||
15 | small employers that are required to provide information | ||||||
16 | regarding their employees to a small employer carrier when | ||||||
17 | applying for a small employer group health insurance policy to | ||||||
18 | use a standardized questionnaire that small employer carriers | ||||||
19 | shall be required to use. The development of the uniform | ||||||
20 | employee health-status questionnaire is intended to relieve | ||||||
21 | small employers of the burden of completing separate | ||||||
22 | application forms for each small employer carrier with which | ||||||
23 | the employer applies for insurance or from which the employer | ||||||
24 | seeks information regarding such matters as rates, coverage, | ||||||
25 | and availability. The use of the uniform employee health-status | ||||||
26 | questionnaire by small employer carriers and small employers |
| |||||||
| |||||||
1 | shall be mandatory. | ||||||
2 | (d) On or before July 1, 2010, the committee shall develop | ||||||
3 | the uniform employee health-status questionnaire for adoption | ||||||
4 | by the Department. Beginning January 1, 2011, a small employer | ||||||
5 | carrier shall use the questionnaire for all small employer | ||||||
6 | groups for which it requires employees and their covered | ||||||
7 | dependents to complete questionnaires. | ||||||
8 | (e) The Director, as needed, may reconvene the committee to | ||||||
9 | consider whether changes are necessary to the uniform employee | ||||||
10 | health status questionnaire. If the committee determines that | ||||||
11 | changes to the questionnaire are necessary, then the Director | ||||||
12 | may adopt revisions to the questionnaire as recommended by the | ||||||
13 | committee. Small employer carriers shall use the revised | ||||||
14 | questionnaire beginning 90 days after the Director adopts any | ||||||
15 | revision. | ||||||
16 | (f) Nothing in this Section shall be construed to limit or | ||||||
17 | restrict a small employer carrier's ability to appropriately | ||||||
18 | rate risk under a small employer health benefit plan. | ||||||
19 | (g) On or before July 1, 2010, the committee shall develop | ||||||
20 | a standard individual market health statement to simplify the | ||||||
21 | health insurance application process for individuals. The | ||||||
22 | committee shall study health statements currently used by major | ||||||
23 | carriers in this State who offer individual health insurance | ||||||
24 | coverage and consolidate the statements into a standard | ||||||
25 | individual market health statement. The standard individual | ||||||
26 | market health statement shall be designed to permit its use |
| |||||||
| |||||||
1 | both as a written document and through electronic or other | ||||||
2 | alternative delivery formats. For purposes of the individual | ||||||
3 | market health statement, the Director may, but shall not be | ||||||
4 | required to, establish a committee distinct from that formed to | ||||||
5 | develop an application for small employers. In that event, the | ||||||
6 | composition of the committee shall be as prescribed in | ||||||
7 | subsection (b) of this Section, although individual | ||||||
8 | participants may change. | ||||||
9 | (h) Beginning January 1, 2011, all carriers who offer | ||||||
10 | individual health insurance coverage and evaluate the health | ||||||
11 | status of individuals shall use the standard individual market | ||||||
12 | health statement. | ||||||
13 | (i) The Director, as needed, may reconvene the committee to | ||||||
14 | consider whether changes are necessary to the standard | ||||||
15 | individual market health statement. If the committee | ||||||
16 | determines that changes to the statement are necessary, the | ||||||
17 | Director may adopt revisions to the statement as recommended by | ||||||
18 | the committee. All carriers who offer individual health | ||||||
19 | insurance coverage shall use the revised statement beginning 90 | ||||||
20 | days after the Director adopts any revision. | ||||||
21 | (j) Nothing in this Section shall prevent a carrier from | ||||||
22 | using health information after enrollment for the purpose of | ||||||
23 | providing services or arranging for the provision of services
| ||||||
24 | under a health benefit plan or a policy of individual health | ||||||
25 | insurance coverage. | ||||||
26 | (k) Nothing in this Section shall be construed to limit or |
| |||||||
| |||||||
1 | restrict a health carrier's ability to appropriately rate risk, | ||||||
2 | refuse to issue or renew coverage, or otherwise rescind, | ||||||
3 | terminate, or restrict coverage under a health benefit plan or | ||||||
4 | a policy of individual health insurance coverage or conduct | ||||||
5 | further review of the information submitted on the statement by | ||||||
6 | contacting an individual, the individual's health care | ||||||
7 | provider, or any other entity for additional health status | ||||||
8 | related information. | ||||||
9 | (l) Committee members are not eligible for compensation but | ||||||
10 | may receive reimbursement of expenses. | ||||||
11 | (215 ILCS 5/359c new)
| ||||||
12 | Sec. 359c. Accident and health expense reporting. | ||||||
13 | (a) Beginning January 1, 2011 and every 6 months | ||||||
14 | thereafter, any carrier providing a group or individual major | ||||||
15 | medical policy of accident or health insurance shall prepare | ||||||
16 | and provide to the Department of Insurance a statement of the | ||||||
17 | aggregate administrative expenses of the carrier, based on the | ||||||
18 | premiums earned in the immediately preceding 6-month period on | ||||||
19 | the accident or health insurance business of the carrier. The | ||||||
20 | semi-annual statements shall be filed on or before July 31 for | ||||||
21 | the preceding 6-month period ending June 30 and on or before | ||||||
22 | February 1 for the preceding 6-month period ending December 31. | ||||||
23 | The statements shall itemize and separately detail all of the | ||||||
24 | following information with respect to the carrier's accident or | ||||||
25 | health insurance business: |
| |||||||
| |||||||
1 | (1) the amount of premiums earned by the carrier both | ||||||
2 | before and after any costs related to the carrier's | ||||||
3 | purchase of reinsurance coverage; | ||||||
4 | (2) the total amount of claims for losses paid by the | ||||||
5 | carrier both before and after any reimbursement from | ||||||
6 | reinsurance coverage including any costs incurred related | ||||||
7 | to: | ||||||
8 | (A) disease, case, or chronic care management | ||||||
9 | programs; | ||||||
10 | (B) wellness and health education programs; | ||||||
11 | (C) fraud prevention; | ||||||
12 | (D) maintaining provider networks and provider | ||||||
13 | credentialing; | ||||||
14 | (E) health information technology for personal | ||||||
15 | electronic health records; and | ||||||
16 | (F) utilization review and utilization management; | ||||||
17 | (3) the amount of any losses incurred by the carrier | ||||||
18 | but not reported to the carrier in the current or prior | ||||||
19 | reporting period; | ||||||
20 | (4) the amount of costs incurred by the carrier for | ||||||
21 | State fees and federal and State taxes including: | ||||||
22 | (A) any high risk pool and guaranty fund | ||||||
23 | assessments levied on the carrier by the State; and | ||||||
24 | (B) any regulatory compliance costs including | ||||||
25 | State fees for form and rate filings, licensures, | ||||||
26 | market conduct exams, and financial reports; |
| |||||||
| |||||||
1 | (5) the amount of costs incurred by the carrier for | ||||||
2 | reinsurance coverage; | ||||||
3 | (6) the amount of costs incurred by the carrier that | ||||||
4 | are related to the carrier's payment of marketing expenses | ||||||
5 | including commissions; and | ||||||
6 | (7) any other administrative expenses incurred by the | ||||||
7 | carrier. | ||||||
8 | (b) The information provided pursuant to subsection (a) of | ||||||
9 | this Section shall be separately aggregated for the following | ||||||
10 | lines of major medical insurance: | ||||||
11 | (1) individually underwritten; | ||||||
12 | (2) groups of 2 to 25 members; | ||||||
13 | (3) groups of 26 to 50 members; | ||||||
14 | (4) groups of 51 or more members. | ||||||
15 | (c) The Department shall make the submitted information | ||||||
16 | publicly available on the Department's website or such other | ||||||
17 | media as appropriate in a form useful for consumers.
| ||||||
18 | Section 95. The Managed Care Reform and Patient Rights Act | ||||||
19 | is amended by changing Sections 40 and 45 as follows:
| ||||||
20 | (215 ILCS 134/40)
| ||||||
21 | Sec. 40. Access to specialists.
| ||||||
22 | (a) All health care plans that require each enrollee to | ||||||
23 | select a
health care provider for any purpose including | ||||||
24 | coordination of
care shall
permit an enrollee to choose any |
| |||||||
| |||||||
1 | available primary care physician licensed to
practice
medicine | ||||||
2 | in all its branches participating in
the health care plan for | ||||||
3 | that purpose.
The health care plan shall provide the enrollee | ||||||
4 | with a choice of licensed
health care providers who are | ||||||
5 | accessible and
qualified. Nothing in
this Act shall be | ||||||
6 | construed to prohibit a health care plan from requiring a
| ||||||
7 | health care provider to meet the health care plan's criteria in | ||||||
8 | order to
coordinate access to health care.
| ||||||
9 | (b) A health care plan shall establish a procedure by which | ||||||
10 | an enrollee who
has a condition that requires ongoing care from | ||||||
11 | a specialist physician
or other health care provider may apply | ||||||
12 | for a
standing referral to a specialist physician or other | ||||||
13 | health care provider if a
referral to a specialist
physician or | ||||||
14 | other health care provider is required for
coverage.
The | ||||||
15 | application shall be made to the enrollee's primary care | ||||||
16 | physician.
This procedure for a standing referral must specify
| ||||||
17 | the necessary criteria and conditions that must be met in order | ||||||
18 | for an enrollee
to obtain a standing referral.
A standing | ||||||
19 | referral shall be effective for the period
necessary to provide | ||||||
20 | the referred services or one year, except in the event of
| ||||||
21 | termination of a contract or policy in which case Section 25 on | ||||||
22 | transition of
services shall apply, if applicable.
A primary | ||||||
23 | care physician may renew and re-renew a standing referral.
| ||||||
24 | (c) The enrollee may be required by the health care plan to | ||||||
25 | select a
specialist physician or other health care provider who | ||||||
26 | has a referral
arrangement with the enrollee's
primary care |
| |||||||
| |||||||
1 | physician or to select a new primary care physician who has a
| ||||||
2 | referral arrangement with the specialist physician or other | ||||||
3 | health care
provider chosen by the enrollee.
If a health care | ||||||
4 | plan requires an enrollee to select a new physician under
this | ||||||
5 | subsection, the health care plan must provide the enrollee with
| ||||||
6 | both
options provided in this subsection.
When a participating | ||||||
7 | specialist with a referral arrangement is not available,
the | ||||||
8 | primary care physician, in consultation with the enrollee, | ||||||
9 | shall arrange
for the enrollee to have access to a qualified | ||||||
10 | participating health care
provider, and the enrollee shall be | ||||||
11 | allowed to stay with his or her primary
care physician.
If a | ||||||
12 | secondary referral is necessary, the specialist physician or | ||||||
13 | other health
care provider shall advise the primary care | ||||||
14 | physician. The primary care
physician shall be responsible for | ||||||
15 | making the secondary referral. In addition,
the health care | ||||||
16 | plan shall require the specialist physician or other health
| ||||||
17 | care
provider to provide regular updates to the enrollee's | ||||||
18 | primary care physician.
| ||||||
19 | (d) When the type of specialist physician or other health | ||||||
20 | care provider
needed to provide ongoing care
for a
specific | ||||||
21 | condition is not represented in the health care plan's provider
| ||||||
22 | network, the primary care physician shall arrange for the | ||||||
23 | enrollee to have
access to
a qualified non-participating health | ||||||
24 | care provider
within a reasonable distance and travel
time at | ||||||
25 | no additional cost beyond what the enrollee would otherwise pay | ||||||
26 | for
services received within the network. The referring |
| |||||||
| |||||||
1 | physician
shall notify the plan when a referral is made outside | ||||||
2 | the network.
| ||||||
3 | (e) The enrollee's primary care physician shall remain | ||||||
4 | responsible for
coordinating the care of an enrollee who has | ||||||
5 | received a standing referral to a
specialist physician or other | ||||||
6 | health care provider.
If a secondary referral is necessary, the | ||||||
7 | specialist physician or other health
care provider shall advise
| ||||||
8 | the primary care physician. The primary care physician shall be | ||||||
9 | responsible
for making the secondary referral.
In addition,
the | ||||||
10 | health care plan shall require the specialist physician or | ||||||
11 | other health
care
provider to provide
regular updates to the | ||||||
12 | enrollee's primary care physician.
| ||||||
13 | (f) If an enrollee's application for any referral is | ||||||
14 | denied, an
enrollee may appeal the decision through the
health | ||||||
15 | care plan's external independent review process as provided by | ||||||
16 | the Illinois Health Carrier External Review Act in accordance | ||||||
17 | with
subsection (f) of Section 45 of this Act .
| ||||||
18 | (g) Nothing in this Act shall be construed to require an | ||||||
19 | enrollee to select
a new primary care physician when no | ||||||
20 | referral arrangement exists between the
enrollee's primary | ||||||
21 | care physician and the specialist selected by the enrollee
and | ||||||
22 | when the enrollee has a long-standing relationship with his or | ||||||
23 | her primary
care physician.
| ||||||
24 | (h) In promulgating rules to implement this Act, the | ||||||
25 | Department shall
define
"standing referral" and "ongoing | ||||||
26 | course of treatment".
|
| |||||||
| |||||||
1 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
2 | (215 ILCS 134/45)
| ||||||
3 | Sec. 45.
Health care services appeals,
complaints, and
| ||||||
4 | external independent reviews.
| ||||||
5 | (a) A health care plan shall establish and maintain an | ||||||
6 | appeals procedure as
outlined in this Act. Compliance with this | ||||||
7 | Act's appeals procedures shall
satisfy a health care plan's | ||||||
8 | obligation to provide appeal procedures under any
other State | ||||||
9 | law or rules.
All appeals of a health care plan's | ||||||
10 | administrative determinations and
complaints regarding its | ||||||
11 | administrative decisions shall be handled as required
under | ||||||
12 | Section 50.
| ||||||
13 | (b) When an appeal concerns a decision or action by a | ||||||
14 | health care plan,
its
employees, or its subcontractors that | ||||||
15 | relates to (i) health care services,
including, but not limited | ||||||
16 | to, procedures or
treatments,
for an enrollee with an ongoing | ||||||
17 | course of treatment ordered
by a health care provider,
the | ||||||
18 | denial of which could significantly
increase the risk to an
| ||||||
19 | enrollee's health,
or (ii) a treatment referral, service,
| ||||||
20 | procedure, or other health care service,
the denial of which | ||||||
21 | could significantly
increase the risk to an
enrollee's health,
| ||||||
22 | the health care plan must allow for the filing of an appeal
| ||||||
23 | either orally or in writing. Upon submission of the appeal, a | ||||||
24 | health care plan
must notify the party filing the appeal, as | ||||||
25 | soon as possible, but in no event
more than 24 hours after the |
| |||||||
| |||||||
1 | submission of the appeal, of all information
that the plan | ||||||
2 | requires to evaluate the appeal.
The health care plan shall | ||||||
3 | render a decision on the appeal within
24 hours after receipt | ||||||
4 | of the required information. The health care plan shall
notify | ||||||
5 | the party filing the
appeal and the enrollee, enrollee's | ||||||
6 | primary care physician, and any health care
provider who | ||||||
7 | recommended the health care service involved in the appeal of | ||||||
8 | its
decision orally
followed-up by a written notice of the | ||||||
9 | determination.
| ||||||
10 | (c) For all appeals related to health care services | ||||||
11 | including, but not
limited to, procedures or treatments for an | ||||||
12 | enrollee and not covered by
subsection (b) above, the health | ||||||
13 | care
plan shall establish a procedure for the filing of such | ||||||
14 | appeals. Upon
submission of an appeal under this subsection, a | ||||||
15 | health care plan must notify
the party filing an appeal, within | ||||||
16 | 3 business days, of all information that the
plan requires to | ||||||
17 | evaluate the appeal.
The health care plan shall render a | ||||||
18 | decision on the appeal within 15 business
days after receipt of | ||||||
19 | the required information. The health care plan shall
notify the | ||||||
20 | party filing the appeal,
the enrollee, the enrollee's primary | ||||||
21 | care physician, and any health care
provider
who recommended | ||||||
22 | the health care service involved in the appeal orally of its
| ||||||
23 | decision followed-up by a written notice of the determination.
| ||||||
24 | (d) An appeal under subsection (b) or (c) may be filed by | ||||||
25 | the
enrollee, the enrollee's designee or guardian, the | ||||||
26 | enrollee's primary care
physician, or the enrollee's health |
| |||||||
| |||||||
1 | care provider. A health care plan shall
designate a clinical | ||||||
2 | peer to review
appeals, because these appeals pertain to | ||||||
3 | medical or clinical matters
and such an appeal must be reviewed | ||||||
4 | by an appropriate
health care professional. No one reviewing an | ||||||
5 | appeal may have had any
involvement
in the initial | ||||||
6 | determination that is the subject of the appeal. The written
| ||||||
7 | notice of determination required under subsections (b) and (c) | ||||||
8 | shall
include (i) clear and detailed reasons for the | ||||||
9 | determination, (ii)
the medical or
clinical criteria for the | ||||||
10 | determination, which shall be based upon sound
clinical | ||||||
11 | evidence and reviewed on a periodic basis, and (iii) in the | ||||||
12 | case of an
adverse determination, the
procedures for requesting | ||||||
13 | an external independent review as provided by the Illinois | ||||||
14 | Health Carrier External Review Act under subsection (f) .
| ||||||
15 | (e) If an appeal filed under subsection (b) or (c) is | ||||||
16 | denied for a reason
including, but not limited to, the
service, | ||||||
17 | procedure, or treatment is not viewed as medically necessary,
| ||||||
18 | denial of specific tests or procedures, denial of referral
to | ||||||
19 | specialist physicians or denial of hospitalization requests or | ||||||
20 | length of
stay requests, any involved party may request an | ||||||
21 | external independent review as provided by the Illinois Health | ||||||
22 | Carrier External Review Act
under subsection (f) of the adverse | ||||||
23 | determination .
| ||||||
24 | (f) Until July 1, 2013, if an external independent review | ||||||
25 | decision made pursuant to the Illinois Health Carrier External | ||||||
26 | Review Act upholds a determination adverse to the covered |
| |||||||
| |||||||
1 | person, the covered person has the right to appeal the final | ||||||
2 | decision to the Department; if the external review decision is | ||||||
3 | found by the Director to have been arbitrary and capricious, | ||||||
4 | then the Director, with consultation from a licensed medical | ||||||
5 | professional, may overturn the external review decision and | ||||||
6 | require the health carrier to pay for the health care service
| ||||||
7 | or treatment; such decision, if any, shall be made solely on
| ||||||
8 | the legal or medical merits of the claim. If an external review | ||||||
9 | decision is overturned by the Director pursuant to this Section | ||||||
10 | and the health carrier so requests, then the Director shall | ||||||
11 | assign a new independent review organization to reconsider the | ||||||
12 | overturned decision. The new independent review organization | ||||||
13 | shall follow subsection (d) of Section 40 of the Health Carrier | ||||||
14 | External Review Act in rendering a decision. External | ||||||
15 | independent review.
| ||||||
16 | (1) The party seeking an external independent review | ||||||
17 | shall so notify the
health care plan.
The health care plan | ||||||
18 | shall seek to resolve all
external independent
reviews in | ||||||
19 | the most expeditious manner and shall make a determination | ||||||
20 | and
provide notice of the determination no more
than 24 | ||||||
21 | hours after the receipt of all necessary information when a | ||||||
22 | delay would
significantly increase
the risk to an | ||||||
23 | enrollee's health or when extended health care services for | ||||||
24 | an
enrollee undergoing a
course of treatment prescribed by | ||||||
25 | a health care provider are at issue.
| ||||||
26 | (2) Within 30 days after the enrollee receives written |
| |||||||
| |||||||
1 | notice of an
adverse
determination,
if the enrollee decides | ||||||
2 | to initiate an external independent review, the
enrollee | ||||||
3 | shall send to the health
care plan a written request for an | ||||||
4 | external independent review, including any
information or
| ||||||
5 | documentation to support the enrollee's request for the | ||||||
6 | covered service or
claim for a covered
service.
| ||||||
7 | (3) Within 30 days after the health care plan receives | ||||||
8 | a request for an
external
independent review from an | ||||||
9 | enrollee, the health care plan shall:
| ||||||
10 | (A) provide a mechanism for joint selection of an | ||||||
11 | external independent
reviewer by the enrollee, the | ||||||
12 | enrollee's physician or other health care
provider,
| ||||||
13 | and the health care plan; and
| ||||||
14 | (B) forward to the independent reviewer all | ||||||
15 | medical records and
supporting
documentation | ||||||
16 | pertaining to the case, a summary description of the | ||||||
17 | applicable
issues including a
statement of the health | ||||||
18 | care plan's decision, the criteria used, and the
| ||||||
19 | medical and clinical reasons
for that decision.
| ||||||
20 | (4) Within 5 days after receipt of all necessary | ||||||
21 | information, the
independent
reviewer
shall evaluate and | ||||||
22 | analyze the case and render a decision that is based on
| ||||||
23 | whether or not the health
care service or claim for the | ||||||
24 | health care service is medically appropriate. The
decision | ||||||
25 | by the
independent reviewer is final. If the external | ||||||
26 | independent reviewer determines
the health care
service to |
| |||||||
| |||||||
1 | be medically
appropriate, the health
care plan shall pay | ||||||
2 | for the health care service.
| ||||||
3 | (5) The health care plan shall be solely responsible | ||||||
4 | for paying the fees
of the external
independent reviewer | ||||||
5 | who is selected to perform the review.
| ||||||
6 | (6) An external independent reviewer who acts in good | ||||||
7 | faith shall have
immunity
from any civil or criminal | ||||||
8 | liability or professional discipline as a result of
acts or | ||||||
9 | omissions with
respect to any external independent review, | ||||||
10 | unless the acts or omissions
constitute wilful and wanton
| ||||||
11 | misconduct. For purposes of any proceeding, the good faith | ||||||
12 | of the person
participating shall be
presumed.
| ||||||
13 | (g) (7) Future contractual or employment action by the | ||||||
14 | health care plan
regarding the
patient's physician or other | ||||||
15 | health care provider shall not be based solely on
the | ||||||
16 | physician's or other
health care provider's participation | ||||||
17 | in health care services appeals,
complaints, or
external | ||||||
18 | independent reviews under the Illinois Health Carrier | ||||||
19 | External Review Act this procedure .
| ||||||
20 | (8) For the purposes of this Section, an external | ||||||
21 | independent reviewer
shall:
| ||||||
22 | (A) be a clinical peer;
| ||||||
23 | (B) have no direct financial interest in | ||||||
24 | connection with the case; and
| ||||||
25 | (C) have not been informed of the specific identity | ||||||
26 | of the enrollee.
|
| |||||||
| |||||||
1 | (h) (g) Nothing in this Section shall be construed to | ||||||
2 | require a health care
plan to pay for a health care service not | ||||||
3 | covered under the enrollee's
certificate of coverage or policy.
| ||||||
4 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
5 | Section 96. No acceleration or delay. Where this Act makes | ||||||
6 | changes in a statute that is represented in this Act by text | ||||||
7 | that is not yet or no longer in effect (for example, a Section | ||||||
8 | represented by multiple versions), the use of that text does | ||||||
9 | not accelerate or delay the taking effect of (i) the changes | ||||||
10 | made by this Act or (ii) provisions derived from any other | ||||||
11 | Public Act. | ||||||
12 | Section 97. Severability. The provisions of this Act are | ||||||
13 | severable under Section 1.31 of the Statute on Statutes. | ||||||
14 | Section 99. Effective date. This Act takes effect January | ||||||
15 | 1, 2010, except that the changes to Section 155.36 of the | ||||||
16 | Illinois Insurance Code and Sections 40 and 45 of the Managed | ||||||
17 | Care Reform and Patient Rights Act and the Health Carrier | ||||||
18 | External Review Act take effect July 1, 2010. |