Illinois General Assembly - Full Text of SB0158
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Full Text of SB0158  102nd General Assembly

SB0158 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB0158

 

Introduced 2/9/2021, by Sen. Linda Holmes

 

SYNOPSIS AS INTRODUCED:
 
New Act
215 ILCS 134/45.2
215 ILCS 134/70
305 ILCS 5/5-5.12d new

    Creates the Prior Authorization Reform Act. Provides requirements concerning disclosure and review of prior authorization requirements, denial of claims or coverage by a utilization review program, and the implementation of prior authorization requirements or restrictions. Provides requirements concerning a utilization review program's obligations with respect to prior authorizations in nonurgent circumstances, urgent health care services, and emergency health care services. Provides that a utilization review program shall not require prior authorization under specified circumstances. Provides requirements concerning the length of prior authorizations. Provides that health care services are automatically deemed authorized if a utilization review program fails to comply with the requirements of the Act. Provides that the Director of Insurance may impose an administrative fine not to exceed $250,000 for violations of the Act. Defines terms. Amends the Managed Care Reform and Patient Rights Act to provide that an insurer that provides prescription drug benefits must comply with the requirements of the Prior Authorization Reform Act. Provides that if prior authorization for covered post-stabilization services is required by a health care plan, the plan shall comply with the requirements of the Prior Authorization Reform Act. Amends the Illinois Public Aid Code to provide that all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act. Makes other changes. Effective January 1, 2022.


LRB102 11324 BMS 16657 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB0158LRB102 11324 BMS 16657 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be cited as the Prior
5Authorization Reform Act.
 
6    Section 5. Purpose. The General Assembly hereby finds and
7declares that:
8    (a) the health care professional-patient relationship is
9paramount and should not be subject to third-party intrusion;
10    (b) prior authorization programs shall not be permitted to
11hinder patient care or intrude on the provision of health care
12services; and
13    (c) prior authorization programs must be transparent to
14ensure a fair and consistent process for patients.
 
15    Section 10. Applicability; scope. This Act applies to
16individual and group policies of accident and health
17insurance, and policies issued or delivered in this State to
18the Department of Healthcare and Family Services and providing
19coverage to persons who are enrolled under Article V of the
20Illinois Public Aid Code or under the Children's Health
21Insurance Program Act, amended, delivered, issued, or renewed
22on or after the effective date of this Act, with the exception

 

 

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1of employee or employer self-insured health benefit plans
2under the federal Employee Retirement Income Security Act of
31974, health care provided pursuant to the Workers'
4Compensation Act or the Workers' Occupational Diseases Act,
5and State employee health plans. This Act does not diminish a
6health care plan's duties and responsibilities under other
7federal or State law or rules promulgated thereunder.
 
8    Section 15. Definitions. As used in this Act:
9    "Adverse determination" means a determination by a
10utilization review program that, based upon the information
11provided, the health care services or level of services
12furnished or a request for health care services or level of
13services to be furnished to an enrollee do not meet the
14utilization review program's requirements for medical
15necessity, appropriateness, health care setting, level of
16service, or effectiveness or is determined to be experimental
17or investigational and the requested benefit coverage is
18therefore denied, reduced, or terminated and payment is not
19provided or made, in whole or in part, for the health care
20service.
21    "Appeal" means a formal request, either orally or in
22writing, to reconsider an adverse determination.
23    "Authorization" means a determination by a utilization
24review program that a health care service has been reviewed
25and, based on the information provided, satisfies the

 

 

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1utilization review program's requirements for medical
2necessity and appropriateness and that payment will be made
3for that health care service.
4    "Clinical review criteria" means the written policies,
5written screening procedures, drug formularies or lists of
6covered drugs, decision rules, decision abstracts, clinical
7protocols, practice guidelines, medical protocols, and any
8other criteria or rationale used by the utilization review
9program to determine the necessity and appropriateness of
10health care services.
11    "Department" means the Department of Insurance.
12    "Emergency health care services" means a medical condition
13manifesting itself by acute symptoms of sufficient severity,
14including severe pain, regardless of the final diagnosis
15given, such that a prudent layperson who possesses an average
16knowledge of health and medicine could reasonably expect the
17absence of immediate medical attention to result in:
18        (1) placing the health of the individual or, with
19    respect to a pregnant woman, the health of the woman or her
20    unborn child in serious jeopardy;
21        (2) serious impairment to bodily functions;
22        (3) serious dysfunction of any bodily organ or part;
23        (4) inadequately controlled pain; or
24        (5) with respect to a pregnant woman who is having
25    contractions:
26            (A) inadequate time to complete a safe transfer to

 

 

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1        another hospital before delivery; or
2            (B) a transfer to another hospital that may pose a
3        threat to the health or safety of the woman or unborn
4        child.
5    "Enrollee" means a person and his or her dependents
6enrolled in or covered by a health plan or other health
7insurance coverage. "Enrollee" includes an enrollee's legally
8authorized representative.
9    "Health care professional" means a physician licensed to
10practice medicine in all its branches, an advanced practice
11registered nurse, or another individual appropriately licensed
12or registered to provide health care services.
13    "Health care provider" means a hospital, hospital facility
14licensed under the Nursing Home Care Act, or long-term care
15facility as defined in Section 1-113 of the Nursing Home Care
16Act.
17    "Health care service" means any services or level of
18services included in the furnishing to an individual of
19medical care or the hospitalization incident to the furnishing
20of such care, as well as the furnishing to any person of any
21other services for the purpose of preventing, alleviating,
22curing, or healing human illness or injury, including
23behavioral health, mental health, home health, and
24pharmaceutical services and products.
25    "Medically necessary" means a health care professional
26exercising prudent clinical judgment would provide care to a

 

 

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1patient for the purpose of preventing, diagnosing, or treating
2an illness, injury, disease, or its symptoms and that are: (i)
3in accordance with generally accepted standards of medical
4practice; (ii) clinically appropriate in terms of type,
5frequency, extent, site, and duration and are considered
6effective for the patient's illness, injury, or disease; and
7(iii) not primarily for the convenience of the patient,
8treating physician, other health care professional, caregiver,
9family member, or other interested party.
10    "Physician" means a person licensed under the Medical
11Practice Act of 1987 to practice medicine in all its branches.
12    "Prior authorization" means the process by which
13utilization review programs determine the medical necessity
14and medical appropriateness of otherwise covered health care
15services for which payment will be made prior to the rendering
16of such health care services. "Prior authorization" includes
17any utilization review program's requirement that an enrollee,
18health care professional, or health care provider notify the
19utilization review program prior to, at the time of, or
20concurrent to providing a health care service.
21    "Urgent health care service" means a health care service
22with respect to which the application of the time periods for
23making a nonexpedited prior authorization that in the opinion
24of a health care professional with knowledge of the enrollee's
25medical condition:
26        (1) could seriously jeopardize the life or health of

 

 

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1    the enrollee or the ability of the enrollee to regain
2    maximum function; or
3        (2) could subject the enrollee to severe pain that
4    cannot be adequately managed without the care or treatment
5    that is the subject of the utilization review.
6    "Utilization review program" means a program established
7to perform prior authorization for or designated by one or
8more of the following entities:
9        (1) an employer with employees in Illinois who are
10    covered under a health benefit plan or health insurance
11    policy;
12        (2) an insurer that offers or issues health insurance
13    policies;
14        (3) a preferred provider organization or health
15    maintenance organization;
16        (4) a pharmacy benefits manager responsible for
17    managing access of enrollees to available pharmaceutical
18    or pharmacological care; or
19        (5) any other individual or program that provides,
20    offers to provide, or administers hospital, outpatient,
21    medical, or other health benefits to a person treated by a
22    health care professional or health care provider in
23    Illinois under a policy, plan, or contract.
 
24    Section 20. Disclosure and review of prior authorization
25requirements.

 

 

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1    (a) A utilization review program shall maintain a complete
2list of services for which prior authorization is required,
3including for all services where prior authorization is
4performed by an entity under contract with the utilization
5review program.
6    (b) A utilization review program shall make any current
7prior authorization requirements and restrictions, including
8the written clinical review criteria, readily accessible and
9conspicuously posted on its website to enrollees, health care
10professionals, health care providers, and the general public.
11Requirements shall be described in detail, written in easily
12understandable language, and readily available to the health
13care professional and health care provider at the point of
14care. The website shall indicate, for each service subject to
15prior authorization:
16        (1) when prior authorization became required for
17    policies issued or delivered in Illinois, including the
18    effective date or dates and the termination date or dates,
19    if applicable, in Illinois;
20        (2) the date the Illinois-specific requirement was
21    listed on the utilization review program's website; and
22        (3) where applicable, the date that prior
23    authorization was removed for Illinois.
24    (c) The clinical review criteria must:
25        (1) be based on nationally recognized standards;
26        (2) be developed in accordance with the current

 

 

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1    standards of national medical accreditation entities;
2        (3) reflect community standards of care;
3        (4) ensure quality of care and access to needed health
4    care services;
5        (5) be evidence-based;
6        (6) be sufficiently flexible to allow deviations from
7    norms when justified on a case-by-case basis;
8        (7) be evaluated and updated, if necessary, at least
9    annually; and
10        (8) before establishing or substantially or materially
11    altering written clinical review criteria, obtain input
12    from actively practicing physicians, representing major
13    areas of the specialty, within the provider network and
14    within the service area where the written clinical review
15    criteria are to be employed. The utilization review
16    program shall seek input from physicians who are not
17    employees of utilization review program or consultants to
18    the utilization review program.
19    (d) A utilization review program shall not deny a claim
20for failure to obtain prior authorization if the prior
21authorization requirement was not in effect on the date of
22service on the claim.
23    (e) A utilization review program shall not deny coverage
24of a health care service solely based on the grounds that the
25health care service does not meet an evidence-based standard
26where:

 

 

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1        (1) no independently-developed, evidence-based
2    standards can be derived from documents published by
3    professional societies;
4        (2) evidence-based standards conflict;
5        (3) evidence-based standards from expert consensus
6    panels do not exist; or
7        (4) existing standards for a particular health care
8    item, service, pharmaceutical product, test, or imaging
9    procedure not directly applicable to the applicable health
10    service are being applied.
11    (f) A utilization review program shall not deem as
12incidental or deny supplies or health care services that are
13routinely used as part of a health care service when:
14        (1) an associated health care service has received
15    prior authorization; or
16        (2) prior authorization for the health care service is
17    not required.
18    (g) If a utilization review program intends to implement a
19new prior authorization requirement or restriction or amend an
20existing requirement or restriction, the utilization review
21program shall provide contracted enrollees, health care
22professionals, and health care providers of enrollees written
23notice of the new or amended requirement or amendment no less
24than 60 days before the requirement or restriction is
25implemented. The written notice may be provided in an
26electronic format, including email or facsimile, if the

 

 

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1enrollee, health care professional, or health care provider
2has agreed in advance to receive notices electronically. The
3utilization review program shall ensure that the new or
4amended requirement is not implemented unless the utilization
5review program's public website has been updated to reflect
6the new or amended requirement or restriction.
7    (h) Entities utilizing prior authorization shall make
8statistics available regarding prior authorization approvals
9and denials on their website in a readily accessible format.
10The categories must be updated monthly and include all of the
11following information:
12        (1) a list of all health care services, including
13    medications, that are subject to prior authorization;
14        (2) the total number of prior authorization requests
15    received;
16        (3) the physician specialty;
17        (4) the number of prior authorization requests
18    approved during the previous plan year by the utilization
19    review program with respect to each service described in
20    paragraph (1);
21        (5) the number of prior authorization requests
22    approved during the previous plan year by the utilization
23    review program after the receipt of additional information
24    from the enrollee, the enrollee's health care
25    professional, or the enrollee's health care provider;
26        (6) the number of prior authorization requests denied

 

 

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1    during the previous plan year by the insurer with respect
2    to each service described in paragraph (1) and the top 10
3    reasons for denial, which must include related
4    evidence-based criteria, if applicable;
5        (7) the number of requests described in paragraph (6)
6    that were appealed, the number of the appealed requests
7    that upheld the adverse determination, and the number of
8    appealed requests that reversed the adverse determination;
9        (8) the time between submission and response;
10        (9) the average length of time for resolution; and
11        (10) any other information as the Director determines
12    appropriate after consultation with and comment from
13    stakeholders.
 
14    Section 25. Utilization review program's obligations with
15respect to prior authorizations in nonurgent circumstances. If
16a utilization review program requires prior authorization of a
17health care service, the utilization review program must make
18a prior authorization or adverse determination and notify the
19enrollee, the enrollee's health care professional, and the
20enrollee's health care provider of the prior authorization or
21adverse determination within 48 hours of obtaining all
22necessary information to make the prior authorization or
23adverse determination. For purposes of this Section,
24"necessary information" includes the results of any
25face-to-face clinical evaluation or second opinion that may be

 

 

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1required.
 
2    Section 30. Utilization review program's obligations with
3respect to prior authorizations concerning urgent health care
4services.
5    (a) A utilization review program must render a prior
6authorization or adverse determination concerning urgent care
7services and notify the enrollee, the enrollee's health care
8professional, and the enrollee's health care provider of that
9prior authorization or adverse determination not later than 24
10hours after receiving all information needed to complete the
11review of the requested health care services.
12    (b) To facilitate the rendering of a prior authorization
13in accordance with this Section, a utilization review program
14must establish and provide access to a hotline that is staffed
1524 hours per day, 7 days per week by appropriately trained and
16licensed clinical personnel who have access to physicians for
17consultation, designated by the plan to make such
18determinations for prior authorization concerning urgent care
19services.
 
20    Section 35. Utilization review program's obligations with
21respect to prior authorization concerning emergency health
22care services.
23    (a) A utilization review program may not require prior
24authorization for pre-hospital transportation or for the

 

 

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1provision of emergency health care services.
2    (b) A utilization review program shall allow an enrollee,
3the enrollee's health care professional, and the enrollee's
4health care provider a minimum of 24 hours following an
5emergency admission or provision of emergency health care
6services for the enrollee, the enrollee's health care
7professional, or the enrollee's health care provider to notify
8the utilization review program of the admission or provision
9of health care services. If the admission or health care
10service occurs on a holiday or weekend, a utilization review
11program cannot require notification until the next business
12day after the admission or provision of the health care
13services.
14    (c) A utilization review program shall cover emergency
15health care services necessary to screen and stabilize an
16enrollee. If a health care professional or health care
17provider certifies in writing to a utilization review program
18within 72 hours after an enrollee's admission that the
19enrollee's condition required emergency health care services,
20that certification will create a presumption that the
21emergency health care services were medically necessary and
22such presumption may be rebutted only if the utilization
23review program can establish, with clear and convincing
24evidence, that the emergency health care services were not
25medically necessary.
26    (d) The medical necessity or appropriateness of emergency

 

 

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1health care services cannot be based on whether or not those
2services were provided by participating or nonparticipating
3providers. Restrictions on coverage of emergency health care
4services provided by nonparticipating providers cannot be
5greater than restrictions that apply when those services are
6provided by participating providers.
7    (e) If an enrollee receives an emergency health care
8service that requires immediate post-evaluation or
9post-stabilization services, a utilization review program
10shall make an authorization determination within 60 minutes
11after receiving a request; if the authorization determination
12is not made within 60 minutes, such services shall be deemed
13approved.
 
14    Section 40. Personnel qualified to make adverse
15determinations. A utilization review program must ensure that
16all adverse determinations are made by a physician. The
17physician must:
18        (1) possess a current and valid nonrestricted license
19    to practice medicine in all its branches in Illinois;
20        (2) practice in the same specialty as the physician
21    who typically manages the medical condition or disease or
22    provides the health care service involved in the request;
23        (3) have experience treating patients with the medical
24    condition or disease for which the health care service is
25    being requested; and

 

 

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1        (4) make the adverse determination under the clinical
2    direction of one of the utilization review program's
3    medical directors who is responsible for the provision of
4    health care services provided to enrollees of Illinois.
5    All such medical directors must be physicians licensed in
6    Illinois.
 
7    Section 45. Consultation prior to issuing an adverse
8determination. If a utilization review program is questioning
9the medical necessity of a health care service, the
10utilization review program must notify the enrollee's health
11care professional and health care provider that medical
12necessity is being questioned. Prior to issuing an adverse
13determination, the enrollee's health care professional and
14health care provider must have the opportunity to discuss the
15medical necessity of the health care service on the telephone
16or by other agreeable method with the physician who will be
17responsible for determining authorization of the health care
18service under review.
 
19    Section 50. Requirements applicable to the physician who
20can review consultations and appeals. A utilization program
21must ensure that all appeals are reviewed by a physician. The
22physician must:
23        (1) possess a current and valid nonrestricted license
24    to practice medicine in Illinois;

 

 

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1        (2) be currently in active practice in the same or
2    similar specialty as physician who typically manages the
3    medical condition or disease for at least 5 consecutive
4    years;
5        (3) be knowledgeable of, and have experience
6    providing, the health care services under appeal;
7        (4) not be employed by a utilization review program or
8    be under contract with the utilization review program
9    other than to participate in one or more of the
10    utilization review program's health care professional
11    networks or to perform reviews of appeals, or otherwise
12    have any financial interest in the outcome of the appeal;
13        (5) not have been directly involved in making the
14    adverse determination; and
15        (6) consider all known clinical aspects of the health
16    care service under review, including, but not limited to,
17    a review of all pertinent medical records provided to the
18    utilization review program by the enrollee's health care
19    professional or health care provider and any medical
20    literature provided to the utilization review program by
21    the health care professional or health care provider.
 
22    Section 55. Limitation on prior authorization. A
23utilization review program shall not require prior
24authorization:
25        (1) where a medication or procedure prescribed for a

 

 

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1    patient is customary and properly indicated or is a
2    treatment for the clinical indication as supported by
3    peer-reviewed medical publications;
4        (2) for a patient currently managed with an
5    established treatment regimen; or
6        (3) for the provision of medication-assisted treatment
7    for the treatment of substance use disorder as those terms
8    are defined in the Substance Use Disorder Act.
 
9    Section 60. Denial.
10    (a) The utilization review program may not revoke, limit,
11condition, or restrict a prior authorization.
12    (b) Notwithstanding any other provision of law, a
13utilization review program shall approve claims and payment
14shall be made on claims for health care services for which
15prior authorization was required and received prior to the
16rendering of health care services, unless one of the following
17occurs:
18        (1) it is timely determined that the enrollee's health
19    care professional or health care provider knowingly
20    provided health care services that required prior
21    authorization from the utilization review program without
22    first obtaining prior authorization for those health care
23    services;
24        (2) it is timely determined that the health care
25    services claimed were not performed;

 

 

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1        (3) it is timely determined that the health care
2    services rendered were contrary to the instructions of the
3    utilization review program or its delegated physician
4    reviewer if contact was made between those parties prior
5    to the service being rendered;
6        (4) it is timely determined that the enrollee
7    receiving such health care services was not an enrollee of
8    the health care plan; or
9        (5) the authorization was based upon a material
10    misrepresentation by the enrollee or health care provider;
11    as used in this paragraph, "material" means a fact or
12    situation that is not merely technical in nature and
13    results or could result in a substantial change in the
14    situation.
 
15    Section 65. Length of prior authorization. A prior
16authorization shall be valid for 15 months after the date the
17health care professional or health care provider receives the
18prior authorization and the authorization period shall be
19effective regardless of any changes, including any changes in
20dosage for a prescription drug prescribed by the health care
21professional.
 
22    Section 70. Length of prior authorization for treatment
23for chronic or long-term care conditions. If a utilization
24review program requires a prior authorization for a health

 

 

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1care service for the treatment of a chronic or long-term care
2condition, the prior authorization shall remain valid for the
3length of the treatment as determined by the patient's health
4care professional and the utilization review program may not
5require the enrollee to obtain a prior authorization again for
6the health care service.
 
7    Section 75. Continuity of care for enrollees.
8    (a) On receipt of information documenting a prior
9authorization from the enrollee or from the enrollee's health
10care professional or health care provider, a utilization
11review program shall honor a prior authorization granted to an
12enrollee from a previous utilization review program for at
13least the initial 90 days of an enrollee's coverage under a new
14health plan.
15    (b) During the time period described in subsection (a), a
16utilization review program may perform its own review to grant
17a prior authorization.
18    (c) If there is a change in coverage of or approval
19criteria for a previously authorized health care service, the
20change in coverage or approval criteria does not affect an
21enrollee who received prior authorization before the effective
22date of the change for the remainder of the enrollee's plan
23year.
24    (d) A utilization review program shall continue to honor a
25prior authorization it has granted to an enrollee when the

 

 

SB0158- 20 -LRB102 11324 BMS 16657 b

1enrollee changes products under the same health insurance
2company.
 
3    Section 80. Health care services deemed authorized if a
4utilization review program fails to comply with the
5requirements of this Act. Any failure by a utilization review
6program to comply with the deadlines and other requirements
7specified in this Act shall result in any health care services
8subject to review to be automatically deemed authorized by the
9utilization review program.
 
10    Section 85. Severability. If any provision of this Act or
11the application thereof to any person or circumstance is held
12invalid, such invalidity shall not affect other provisions or
13applications of this Act which can be given effect without the
14invalid provision or application, and to this end the
15provisions of this Act are declared to be severable.
 
16    Section 90. Administration and enforcement.
17    (a) The Department shall enforce the provisions of this
18Act pursuant to the enforcement powers granted to it by law. To
19enforce the provisions of this Act, the Director is hereby
20granted specific authority to issue a cease and desist order
21or require a utilization review program or insurer to submit a
22plan of correction for violations of this Act, or both.
23Subject to the provisions of the Illinois Administrative

 

 

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1Procedure Act, the Director may, pursuant to Section 403A of
2the Illinois Insurance Code, impose upon a utilization review
3program or insurer an administrative fine not to exceed
4$250,000 for failure to submit a requested plan of correction,
5failure to comply with its plan of correction, or repeated
6violations of this Act.
7    (b) Any person who believes that his or her utilization
8review program or insurer is in violation of the provisions of
9this Act may file a complaint with the Department. The
10Department shall review all complaints received and
11investigate all of those complaints that it deems to state a
12potential violation. The Department shall fairly, efficiently,
13and timely review and investigate complaints. Utilization
14review programs found to be in violation of this Act shall be
15penalized in accordance with this Section.
16    (c) The Department of Healthcare and Family Services shall
17enforce the provisions of this Act as it applies to persons
18enrolled under Article V of the Illinois Public Aid Code or
19under the Children's Health Insurance Program Act.
 
20    Section 900. The Managed Care Reform and Patient Rights
21Act is amended by changing Sections 45.2 and 70 as follows:
 
22    (215 ILCS 134/45.2)
23    Sec. 45.2. Prior authorization form; prescription
24benefits.

 

 

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1    (a) Notwithstanding any other provision of law, on and
2after January 1, 2015, a health insurer that provides
3prescription drug benefits must comply with the requirements
4of the Prior Authorization Reform Act , within 72 hours after
5receipt of a paper or electronic prior authorization form from
6a prescribing provider or pharmacist, either approve or deny
7the prior authorization. In the case of a denial, the insurer
8shall provide the prescriber with the reason for the denial,
9an alternative covered medication, if applicable, and
10information regarding the denial.
11    In the case of an expedited coverage determination, the
12health insurer must either approve or deny the prior
13authorization within 24 hours after receipt of the paper or
14electronic prior authorization form. In the case of a denial,
15the health insurer shall provide the prescriber with the
16reason for the denial, an alternative covered medication, if
17applicable, and information regarding the procedure for
18submitting an appeal to the denial.
19    (b) This Section does not apply to plans for beneficiaries
20of Medicare or Medicaid.
21    (c) For the purposes of this Section:
22    "Pharmacist" has the same meaning as set forth in the
23Pharmacy Practice Act.
24    "Prescribing provider" includes a provider authorized to
25write a prescription, as described in subsection (e) of
26Section 3 of the Pharmacy Practice Act, to treat a medical

 

 

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1condition of an insured.
2(Source: P.A. 98-1035, eff. 8-25-14.)
 
3    (215 ILCS 134/70)
4    Sec. 70. Post-stabilization medical services.
5    (a) If prior authorization for covered post-stabilization
6services is required by the health care plan, the plan shall
7comply with the requirements of the Prior Authorization Reform
8Act provide access 24 hours a day, 7 days a week to persons
9designated by the plan to make such determinations, provided
10that any determination made under this Section must be made by
11a health care professional. The review shall be resolved in
12accordance with the provisions of Section 85 and the time
13requirements of this Section.
14    (b) The treating physician licensed to practice medicine
15in all its branches or health care provider shall contact the
16health care plan or delegated health care provider as
17designated on the enrollee's health insurance card to obtain
18authorization, denial, or arrangements for an alternate plan
19of treatment or transfer of the enrollee.
20    (c) The treating physician licensed to practice medicine
21in all its branches or health care provider shall document in
22the enrollee's medical record the enrollee's presenting
23symptoms; emergency medical condition; and time, phone number
24dialed, and result of the communication for request for
25authorization of post-stabilization medical services. The

 

 

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1health care plan shall provide reimbursement for covered
2post-stabilization medical services if:
3        (1) authorization to render them is received from the
4    health care plan or its delegated health care provider, or
5        (2) after 2 documented good faith efforts, the
6    treating health care provider has attempted to contact the
7    enrollee's health care plan or its delegated health care
8    provider, as designated on the enrollee's health insurance
9    card, for prior authorization of post-stabilization
10    medical services and neither the plan nor designated
11    persons were accessible or the authorization was not
12    denied within 60 minutes of the request. "Two documented
13    good faith efforts" means the health care provider has
14    called the telephone number on the enrollee's health
15    insurance card or other available number either 2 times or
16    one time and an additional call to any referral number
17    provided. "Good faith" means honesty of purpose, freedom
18    from intention to defraud, and being faithful to one's
19    duty or obligation. For the purpose of this Act, good
20    faith shall be presumed.
21    (d) After rendering any post-stabilization medical
22services, the treating physician licensed to practice medicine
23in all its branches or health care provider shall continue to
24make every reasonable effort to contact the health care plan
25or its delegated health care provider regarding authorization,
26denial, or arrangements for an alternate plan of treatment or

 

 

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1transfer of the enrollee until the treating health care
2provider receives instructions from the health care plan or
3delegated health care provider for continued care or the care
4is transferred to another health care provider or the patient
5is discharged.
6    (e) Payment for covered post-stabilization services may be
7denied:
8        (1) if the treating health care provider does not meet
9    the conditions outlined in subsection (c);
10        (2) upon determination that the post-stabilization
11    services claimed were not performed;
12        (3) upon timely determination that the
13    post-stabilization services rendered were contrary to the
14    instructions of the health care plan or its delegated
15    health care provider if contact was made between those
16    parties prior to the service being rendered;
17        (4) upon determination that the patient receiving such
18    services was not an enrollee of the health care plan; or
19        (5) upon material misrepresentation by the enrollee or
20    health care provider; "material" means a fact or situation
21    that is not merely technical in nature and results or
22    could result in a substantial change in the situation.
23    (f) Nothing in this Section prohibits a health care plan
24from delegating tasks associated with the responsibilities
25enumerated in this Section to the health care plan's
26contracted health care providers or another entity. Only a

 

 

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1clinical peer may make an adverse determination. However, the
2ultimate responsibility for coverage and payment decisions may
3not be delegated.
4    (g) Coverage and payment for post-stabilization medical
5services for which prior authorization or deemed approval is
6received shall not be retrospectively denied.
7    (h) Nothing in this Section shall prohibit the imposition
8of deductibles, copayments, and co-insurance. Nothing in this
9Section alters the prohibition on billing enrollees contained
10in the Health Maintenance Organization Act.
11(Source: P.A. 91-617, eff. 1-1-00.)
 
12    Section 905. The Illinois Public Aid Code is amended by
13adding Section 5-5.12d as follows:
 
14    (305 ILCS 5/5-5.12d new)
15    Sec. 5-5.12d. Managed care organization prior
16authorization of health care services.
17    (a) As used in this Section, "health care service" has the
18meaning given to that term in the Prior Authorization Reform
19Act.
20    (b) Notwithstanding any other provision of law to the
21contrary, all managed care organizations shall comply with the
22requirements of the Prior Authorization Reform Act.
 
23    Section 999. Effective date. This Act takes effect January
241, 2022.