Full Text of HB6837 93rd General Assembly
HB6837 93RD GENERAL ASSEMBLY
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93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004 HB6837
Introduced 02/09/04, by Mary E. Flowers SYNOPSIS AS INTRODUCED: |
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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.
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A BILL FOR
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HB6837 |
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LRB093 20734 SAS 46624 b |
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois, | 3 |
| represented in the General Assembly:
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| Section 5. The Illinois Insurance Code is amended by adding | 5 |
| Sections 155.42
as follows:
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| (215 ILCS 5/155.42 new)
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| Sec. 155.42. External independent review. Denial of | 8 |
| coverage; appeals and external independent reviews.
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| (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.
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| (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
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| 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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HB6837 |
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LRB093 20734 SAS 46624 b |
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| 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
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| determination.
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| (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
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| 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
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| 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.
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| (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
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| 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
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| 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).
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| (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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HB6837 |
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LRB093 20734 SAS 46624 b |
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| 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.
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| (f) External independent review.
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| (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
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| 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.
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| (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
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| 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.
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| (3) Within 30 days after the insurer receives a request | 25 |
| for an external
independent review from an insured, the | 26 |
| insurer shall:
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| (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
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| (B) forward to the independent reviewer all | 32 |
| medical records and
supporting documentation | 33 |
| pertaining to the case, a summary description of the
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| 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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HB6837 |
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LRB093 20734 SAS 46624 b |
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| (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.
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| (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.
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| (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,
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| 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.
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| (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
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| procedure.
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| (8) For the purposes of this Section, an external | 26 |
| independent reviewer
shall:
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| (A) be a clinical peer;
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| (B) have no direct financial interest in | 29 |
| connection with the case; and
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| (C) have not been informed of the specific identity | 31 |
| of the insured.
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| (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.
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| (h) For the purposes of this Section, an "insurer" offers a | 36 |
| health care plan (plan) that establishes, operates, or |
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| 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.
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