Full Text of HB4223 95th General Assembly
HB4223ham002 95TH GENERAL ASSEMBLY
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Rep. Mary E. Flowers
Filed: 3/4/2008
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09500HB4223ham002 |
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LRB095 15305 AMC 47284 a |
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| AMENDMENT TO HOUSE BILL 4223
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| AMENDMENT NO. ______. Amend House Bill 4223, on page 4, | 3 |
| line 17, by deleting " or "; and | 4 |
| on page 4, line 20, after " health ", by inserting " , or (iii) | 5 |
| nonrenewal or termination of a policy or plan "; and | 6 |
| on page 15, immediately below line 8, by inserting the | 7 |
| following:
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| "Section 37. The Managed Care Reform and Patient Rights Act | 9 |
| is amended by changing Section 45 as follows:
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| (215 ILCS 134/45)
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| Sec. 45. Health care services appeals,
complaints, and
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| external independent reviews.
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| (a) A health care plan shall establish and maintain an | 14 |
| appeals procedure as
outlined in this Act. Compliance with this |
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LRB095 15305 AMC 47284 a |
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| Act's appeals procedures shall
satisfy a health care plan's | 2 |
| obligation to provide appeal procedures under any
other State | 3 |
| law or rules.
All appeals of a health care plan's | 4 |
| administrative determinations and
complaints regarding its | 5 |
| administrative decisions shall be handled as required
under | 6 |
| Section 50.
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| (b) When an appeal concerns a decision or action by a | 8 |
| health care plan,
its
employees, or its subcontractors that | 9 |
| relates to (i) health care services,
including, but not limited | 10 |
| to, procedures or
treatments,
for an enrollee with an ongoing | 11 |
| course of treatment ordered
by a health care provider,
the | 12 |
| denial of which could significantly
increase the risk to an
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| enrollee's health,
or (ii) a treatment referral, service,
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| procedure, or other health care service,
the denial of which | 15 |
| could significantly
increase the risk to an
enrollee's health , | 16 |
| or (iii) nonrenewal or termination of a plan ,
the health care | 17 |
| plan must allow for the filing of an appeal
either orally or in | 18 |
| writing. Upon submission of the appeal, a health care plan
must | 19 |
| notify the party filing the appeal, as soon as possible, but in | 20 |
| no event
more than 24 hours after the submission of the appeal, | 21 |
| of all information
that the plan requires to evaluate the | 22 |
| appeal.
The health care plan shall render a decision on the | 23 |
| appeal within
24 hours after receipt of the required | 24 |
| information. The health care plan shall
notify the party filing | 25 |
| the
appeal and the enrollee, enrollee's primary care physician, | 26 |
| and any health care
provider who recommended the health care |
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LRB095 15305 AMC 47284 a |
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| service involved in the appeal of its
decision orally
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| followed-up by a written notice of the determination.
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| (c) For all appeals related to health care services | 4 |
| including, but not
limited to, procedures or treatments for an | 5 |
| enrollee and not covered by
subsection (b) above, the health | 6 |
| care
plan shall establish a procedure for the filing of such | 7 |
| appeals. Upon
submission of an appeal under this subsection, a | 8 |
| health care plan must notify
the party filing an appeal, within | 9 |
| 3 business days, of all information that the
plan requires to | 10 |
| evaluate the appeal.
The health care plan shall render a | 11 |
| decision on the appeal within 15 business
days after receipt of | 12 |
| the required information. The health care plan shall
notify the | 13 |
| party filing the appeal,
the enrollee, the enrollee's primary | 14 |
| care physician, and any health care
provider
who recommended | 15 |
| the health care service involved in the appeal orally of its
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| decision followed-up by a written notice of the determination.
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| (d) An appeal under subsection (b) or (c) may be filed by | 18 |
| the
enrollee, the enrollee's designee or guardian, the | 19 |
| enrollee's primary care
physician, or the enrollee's health | 20 |
| care provider. A health care plan shall
designate a clinical | 21 |
| peer to review
appeals, because these appeals pertain to | 22 |
| medical or clinical matters
and such an appeal must be reviewed | 23 |
| by an appropriate
health care professional. No one reviewing an | 24 |
| appeal may have had any
involvement
in the initial | 25 |
| determination that is the subject of the appeal. The written
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| notice of determination required under subsections (b) and (c) |
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| shall
include (i) clear and detailed reasons for the | 2 |
| determination, (ii)
the medical or
clinical criteria for the | 3 |
| determination, which shall be based upon sound
clinical | 4 |
| evidence and reviewed on a periodic basis, and (iii) in the | 5 |
| case of an
adverse determination, the
procedures for requesting | 6 |
| an external independent review under subsection (f).
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| (e) If an appeal filed under subsection (b) or (c) is | 8 |
| denied for a reason
including, but not limited to, the
service, | 9 |
| procedure, or treatment is not viewed as medically necessary,
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| denial of specific tests or procedures, denial of referral
to | 11 |
| specialist physicians or denial of hospitalization requests or | 12 |
| length of
stay requests, any involved party may request an | 13 |
| external independent review
under subsection (f) of the adverse | 14 |
| determination.
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| (f) External independent review.
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| (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.
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| (2) Within 30 days after the enrollee receives written |
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LRB095 15305 AMC 47284 a |
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| 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
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| documentation to support the enrollee's request for the | 6 |
| covered service or
claim for a covered
service.
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| (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:
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| (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,
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| and the health care plan; and
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| (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
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| medical and clinical reasons
for that decision.
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| (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
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| 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 |
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LRB095 15305 AMC 47284 a |
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| be medically
appropriate, the health
care plan shall pay | 2 |
| for the health care service.
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| (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.
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| (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
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| misconduct. For purposes of any proceeding, the good faith | 12 |
| of the person
participating shall be
presumed.
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| (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 this procedure.
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| (8) For the purposes of this Section, an external | 19 |
| independent reviewer
shall:
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| (A) be a clinical peer;
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| (B) have no direct financial interest in | 22 |
| connection with the case; and
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| (C) have not been informed of the specific identity | 24 |
| of the enrollee.
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| (g) Nothing in this Section shall be construed to require a | 26 |
| health care
plan to pay for a health care service not covered |
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| under the enrollee's
certificate of coverage or policy.
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| (h) Notwithstanding any other rulemaking authority that | 3 |
| may exist, neither the Governor nor any agency or agency head | 4 |
| under the jurisdiction of the Governor has any authority to | 5 |
| make or promulgate rules to implement or enforce the provisions | 6 |
| of this amendatory Act of the 95th General Assembly. If, | 7 |
| however, the Governor believes that rules are necessary to | 8 |
| implement or enforce the provisions of this amendatory Act of | 9 |
| the 95th General Assembly, the Governor may suggest rules to | 10 |
| the General Assembly by filing them with the Clerk of the House | 11 |
| and the Secretary of the Senate and by requesting that the | 12 |
| General Assembly authorize such rulemaking by law, enact those | 13 |
| suggested rules into law, or take any other appropriate action | 14 |
| in the General Assembly's discretion. Nothing contained in this | 15 |
| amendatory Act of the 95th General Assembly shall be | 16 |
| interpreted to grant rulemaking authority under any other | 17 |
| Illinois statute where such authority is not otherwise | 18 |
| explicitly given. For the purposes of this amendatory Act of | 19 |
| the 95th General Assembly, "rules" is given the meaning | 20 |
| contained in Section 1-70 of the Illinois Administrative | 21 |
| Procedure Act, and "agency" and "agency head" are given the | 22 |
| meanings contained in Sections 1-20 and 1-25 of the Illinois | 23 |
| Administrative Procedure Act to the extent that such | 24 |
| definitions apply to agencies or agency heads under the | 25 |
| jurisdiction of the Governor. | 26 |
| (Source: P.A. 91-617, eff. 1-1-00.)".
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