93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB6837

 

Introduced 02/09/04, by Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/155.42 new

    Amends the Illinois Insurance Code. Requires an insurer to establish and maintain a procedure for dealing with appeals of the insurer's administrative determinations and complaints regarding its administrative decisions. Provides that an appeal may be filed by an insured or his or her designee or guardian, physician, or health care provider. Requires an insurer to designate a clinical peer to review appeals. Provides that if an appeal is denied, the person who requested the appeal may request an external independent review of the denial. Provides procedures for external independent review.


LRB093 20734 SAS 46624 b

 

 

A BILL FOR

 

HB6837 LRB093 20734 SAS 46624 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by adding
5 Sections 155.42 as follows:
 
6     (215 ILCS 5/155.42 new)
7     Sec. 155.42. External independent review. Denial of
8 coverage; appeals and external independent reviews.
9     (a) An insurer shall establish and maintain an appeals
10 procedure as outlined in this Section. Compliance with this
11 Section's appeals procedures shall satisfy an insurer's
12 obligation to provide appeal procedures under any other State
13 law or rules. All appeals of an insurer's administrative
14 determinations and complaints regarding its administrative
15 decisions shall be handled as required under this Section.
16     (b) When an appeal concerns a decision or action by an
17 insurer, its employees, or its subcontractors that relates to
18 (i) health care services, including, but not limited to,
19 procedures or treatments, for an insured with an ongoing course
20 of treatment ordered by a health care provider, the denial of
21 which could significantly increase the risk to an insured's
22 health, or (ii) a treatment referral, service, procedure, or
23 other health care service, the denial of which could
24 significantly increase the risk to an insured's health, the
25 insurer must allow for the filing of an appeal either orally or
26 in writing. Upon submission of the appeal, an insurer must
27 notify the party filing the appeal, as soon as possible, but in
28 no event more than 24 hours after the submission of the appeal,
29 of all information that the insurer requires to evaluate the
30 appeal. The insurer shall render a decision on the appeal
31 within 24 hours after receipt of the required information. The
32 insurer shall notify the party filing the appeal and the

 

 

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1 insured, insured's physician, and any health care provider who
2 recommended the health care service involved in the appeal of
3 its decision orally followed-up by a written notice of the
4 determination.
5     (c) For all appeals related to health care services
6 including, but not limited to, procedures or treatments for an
7 insured and not covered by subsection (b), the insurer shall
8 establish a procedure for the filing of those appeals. Upon
9 submission of an appeal under this subsection, an insurer must
10 notify the party filing an appeal, within 3 business days, of
11 all information that the insurer requires to evaluate the
12 appeal. The insurer shall render a decision on the appeal
13 within 15 business days after receipt of the required
14 information. The insurer shall notify the party filing the
15 appeal, the insured, the insured's physician, and any health
16 care provider who recommended the health care service involved
17 in the appeal orally of its decision followed-up by a written
18 notice of the determination.
19     (d) An appeal under subsection (b) or (c) may be filed by
20 the insured, the insured's designee or guardian, the insured's
21 physician, or the insured's health care provider. An insurer
22 shall designate a clinical peer to review appeals, because
23 these appeals pertain to medical or clinical matters and such
24 an appeal must be reviewed by an appropriate health care
25 professional. No one reviewing an appeal may have had any
26 involvement in the initial determination that is the subject of
27 the appeal. The written notice of determination required under
28 subsections (b) and (c) shall include (i) clear and detailed
29 reasons for the determination, (ii) the medical or clinical
30 criteria for the determination, which shall be based upon sound
31 clinical evidence and reviewed on a periodic basis, and (iii)
32 in the case of an adverse determination, the procedures for
33 requesting an external independent review under subsection
34 (f).
35     (e) If an appeal filed under subsection (b) or (c) is
36 denied for a reason including, but not limited to, the service,

 

 

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1 procedure, or treatment is not viewed as medically necessary,
2 denial of specific tests or procedures, or denial of
3 hospitalization requests or length of stay requests, any
4 involved party may request an external independent review under
5 subsection (f) of the adverse determination.
6     (f) External independent review.
7         (1) The party seeking an external independent review
8     shall so notify the insurer. The insurer shall seek to
9     resolve all external independent reviews in the most
10     expeditious manner and shall make a determination and
11     provide notice of the determination no more than 24 hours
12     after the receipt of all necessary information when a delay
13     would significantly increase the risk to an insured's
14     health or when extended health care services for an insured
15     undergoing a course of treatment prescribed by a health
16     care provider are at issue.
17         (2) Within 30 days after the insured receives written
18     notice of an adverse determination, if the insured decides
19     to initiate an external independent review, the insured
20     shall send to the insurer a written request for an external
21     independent review, including any information or
22     documentation to support the insured's request for the
23     covered service or claim for a covered service.
24         (3) Within 30 days after the insurer receives a request
25     for an external independent review from an insured, the
26     insurer shall:
27             (A) provide a mechanism for joint selection of an
28         external independent reviewer by the insured, the
29         insured's physician or other health care provider, and
30         the insurer; and
31             (B) forward to the independent reviewer all
32         medical records and supporting documentation
33         pertaining to the case, a summary description of the
34         applicable issues including a statement of the
35         insurer's decision, the criteria used, and the medical
36         and clinical reasons for that decision.

 

 

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1         (4) Within 5 days after receipt of all necessary
2     information, the independent reviewer shall evaluate and
3     analyze the case and render a decision that is based on
4     whether or not the health care service or claim for the
5     health care service is medically appropriate. The decision
6     by the independent reviewer is final. If the external
7     independent reviewer determines the health care service to
8     be medically appropriate, the insurer shall pay for the
9     health care service.
10         (5) The insurer shall be solely responsible for paying
11     the fees of the external independent reviewer who is
12     selected to perform the review.
13         (6) An external independent reviewer who acts in good
14     faith shall have immunity from any civil or criminal
15     liability or professional discipline as a result of acts or
16     omissions with respect to any external independent review,
17     unless the acts or omissions constitute wilful and wanton
18     misconduct. For purposes of any proceeding, the good faith
19     of the person participating shall be presumed.
20         (7) Future contractual or employment action by the
21     insurer regarding the patient's physician or other health
22     care provider shall not be based solely on the physician's
23     or other health care provider's participation in this
24     procedure.
25         (8) For the purposes of this Section, an external
26     independent reviewer shall:
27             (A) be a clinical peer;
28             (B) have no direct financial interest in
29         connection with the case; and
30             (C) have not been informed of the specific identity
31         of the insured.
32     (g) Nothing in this Section shall be construed to require
33 an insurer to pay for a health care service not covered under
34 the insured's policy.
35     (h) For the purposes of this Section, an "insurer" offers a
36 health care plan (plan) that establishes, operates, or

 

 

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1 maintains a network of health care providers that has entered
2 into an agreement with the plan to provide health care services
3 to enrollees to whom the plan has the ultimate obligation to
4 arrange for the provision of or payment for services through
5 organizational arrangements for ongoing quality assurance,
6 utilization review programs, or dispute resolution. Nothing in
7 this definition shall be construed to mean that an independent
8 practice association or a physician hospital organization that
9 subcontracts with a health care plan is, for purposes of that
10 subcontract, a health care plan.
11     For purposes of this definition, "health care plan" shall
12 not include the following:
13         (1) indemnity health insurance policies including
14     those using a contracted provider network;
15         (2) health care plans that offer only dental or only
16     vision coverage;
17         (3) preferred provider administrators, as defined in
18     Section 370g(g) of the Illinois Insurance Code;
19         (4) employee or employer self-insured health benefit
20     plans under the federal Employee Retirement Income
21     Security Act of 1974;
22         (5) health care provided pursuant to the Workers'
23     Compensation Act or the Workers' Occupational Diseases
24     Act; and
25         (6) not-for-profit voluntary health services plans
26     with health maintenance organization authority in
27     existence as of January 1, 1999 that are affiliated with a
28     union and that only extend coverage to union members and
29     their dependents.