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