Full Text of HB3923 96th General Assembly
HB3923sam002 96TH GENERAL ASSEMBLY
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Sen. Heather Steans
Filed: 5/26/2009
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| AMENDMENT TO HOUSE BILL 3923
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| AMENDMENT NO. ______. Amend House Bill 3923 by replacing | 3 |
| everything after the enacting clause with the following:
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| "Section 1. Short title. This Act may be cited as the | 5 |
| Health Carrier External Review Act. | 6 |
| Section 5. Purpose and intent. The purpose of this Act is | 7 |
| to provide uniform standards for the establishment and | 8 |
| maintenance of external review procedures to assure that | 9 |
| covered persons have the opportunity for an independent review | 10 |
| of an adverse determination or final adverse determination, as | 11 |
| defined in this Act. | 12 |
| Section 10. Definitions. For the purposes of this Act: | 13 |
| "Adverse determination" means a determination by a health | 14 |
| carrier or its designee utilization review organization that an | 15 |
| admission, availability of care, continued stay, or other |
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| health care service that is a covered benefit has been reviewed | 2 |
| and, based upon the information provided, does not meet the | 3 |
| health carrier's requirements for medical necessity, | 4 |
| appropriateness, health care setting, level of care, or | 5 |
| effectiveness, and the requested service or payment for the | 6 |
| service is therefore denied, reduced, or terminated. | 7 |
| "Authorized representative" means: | 8 |
| (1) a person to whom a covered person has given express | 9 |
| written consent to represent the covered person in an | 10 |
| external review, including the covered person's health | 11 |
| care provider; | 12 |
| (2) a person authorized by law to provide substituted | 13 |
| consent for a covered person; or | 14 |
| (3) the covered person's health care provider when the | 15 |
| covered person is unable to provide consent. | 16 |
| "Best evidence" means evidence based on: | 17 |
| (1) randomized clinical trials; | 18 |
| (2) if randomized clinical trials are not available, | 19 |
| then cohort studies or case-control studies; | 20 |
| (3) if items (1) and (2) are not available, then | 21 |
| case-series; or | 22 |
| (4) if items (1), (2), and (3) are not available, then | 23 |
| expert opinion. | 24 |
| "Case-series" means an evaluation of a series of patients | 25 |
| with a particular outcome, without the use of a control group. | 26 |
| "Clinical review criteria" means the written screening |
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| procedures, decision abstracts, clinical protocols, and | 2 |
| practice guidelines used by a health carrier to determine the | 3 |
| necessity and appropriateness of health care services. | 4 |
| "Cohort study" means a prospective evaluation of 2 groups | 5 |
| of patients with only one group of patients receiving specific | 6 |
| intervention. | 7 |
| "Covered benefits" or "benefits" means those health care | 8 |
| services to which a covered person is entitled under the terms | 9 |
| of a health benefit plan. | 10 |
| "Covered person" means a policyholder, subscriber, | 11 |
| enrollee, or other individual participating in a health benefit | 12 |
| plan. | 13 |
| "Director" means the Director of the Department of | 14 |
| Insurance. | 15 |
| "Emergency medical condition" means a medical condition | 16 |
| manifesting itself by acute symptoms of sufficient severity, | 17 |
| including, but not limited to, severe pain, such that a prudent | 18 |
| layperson who possesses an average knowledge of health and | 19 |
| medicine could reasonably expect the absence of immediate | 20 |
| medical attention to result in: | 21 |
| (1) placing the health of the individual or, with | 22 |
| respect to a pregnant woman, the health of the woman or her | 23 |
| unborn child, in serious jeopardy; | 24 |
| (2) serious impairment to bodily functions; or
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| (3) serious dysfunction of any bodily organ or part. | 26 |
| "Emergency services" means health care items and services |
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| furnished or required to evaluate and treat an emergency | 2 |
| medical condition. | 3 |
| "Evidence-based standard" means the conscientious, | 4 |
| explicit, and judicious use of the current best evidence based | 5 |
| on an overall systematic review of the research in making | 6 |
| decisions about the care of individual patients. | 7 |
| "Expert opinion" means a belief or an interpretation by | 8 |
| specialists with experience in a specific area about the | 9 |
| scientific evidence pertaining to a particular service, | 10 |
| intervention, or therapy. | 11 |
| "Facility" means an institution providing health care | 12 |
| services or a health care setting. | 13 |
| "Final adverse determination" means an adverse | 14 |
| determination involving a covered benefit that has been upheld | 15 |
| by a health carrier, or its designee utilization review | 16 |
| organization, at the completion of the health carrier's | 17 |
| internal grievance process procedures as set forth by the | 18 |
| Managed Care Reform and Patient Rights Act. | 19 |
| "Health benefit plan" means a policy, contract, | 20 |
| certificate, plan, or agreement offered or issued by a health | 21 |
| carrier to provide, deliver, arrange for, pay for, or reimburse | 22 |
| any of the costs of health care services. | 23 |
| "Health care provider" or "provider" means a physician, | 24 |
| hospital facility, or other health care practitioner licensed, | 25 |
| accredited, or certified to perform specified health care | 26 |
| services consistent with State law, responsible for |
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| recommending health care services on behalf of a covered | 2 |
| person. | 3 |
| "Health care services" means services for the diagnosis, | 4 |
| prevention, treatment, cure, or relief of a health condition, | 5 |
| illness, injury, or disease. | 6 |
| "Health carrier" means an entity subject to the insurance | 7 |
| laws and regulations of this State, or subject to the | 8 |
| jurisdiction of the Director, that contracts or offers to | 9 |
| contract to provide, deliver, arrange for, pay for, or | 10 |
| reimburse any of the costs of health care services, including a | 11 |
| sickness and accident insurance company, a health maintenance | 12 |
| organization, or any other entity providing a plan of health | 13 |
| insurance, health benefits, or health care services. "Health | 14 |
| carrier" also means Limited Health Service Organizations | 15 |
| (LHSO) and Voluntary Health Service Plans. | 16 |
| "Health information" means information or data, whether | 17 |
| oral or recorded in any form or medium, and personal facts or | 18 |
| information about events or relationships that relate to:
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| (1) the past, present, or future physical, mental, or | 20 |
| behavioral health or condition of an individual or a member | 21 |
| of the individual's family; | 22 |
| (2) the provision of health care services to an | 23 |
| individual; or | 24 |
| (3) payment for the provision of health care services | 25 |
| to an individual. | 26 |
| "Independent review organization" means an entity that |
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| conducts independent external reviews of adverse | 2 |
| determinations and final adverse determinations. | 3 |
| "Medical or scientific evidence" means evidence found in | 4 |
| the following sources: | 5 |
| (1) peer-reviewed scientific studies published in or | 6 |
| accepted for publication by medical journals that meet | 7 |
| nationally recognized requirements for scientific | 8 |
| manuscripts and that submit most of their published | 9 |
| articles for review by experts who are not part of the | 10 |
| editorial staff; | 11 |
| (2) peer-reviewed medical literature, including | 12 |
| literature relating to therapies reviewed and approved by a | 13 |
| qualified institutional review board, biomedical | 14 |
| compendia, and other medical literature that meet the | 15 |
| criteria of the National Institutes of Health's Library of | 16 |
| Medicine for indexing in Index Medicus (Medline) and | 17 |
| Elsevier Science Ltd. for indexing in Excerpta Medicus | 18 |
| (EMBASE); | 19 |
| (3) medical journals recognized by the Secretary of | 20 |
| Health and Human Services under Section 1861(t)(2) of the | 21 |
| federal Social Security Act; | 22 |
| (4) the following standard reference compendia:
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| (a) The American Hospital Formulary Service-Drug | 24 |
| Information; | 25 |
| (b) Drug Facts and Comparisons; | 26 |
| (c) The American Dental Association Accepted |
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| Dental Therapeutics; and | 2 |
| (d) The United States Pharmacopoeia-Drug | 3 |
| Information; | 4 |
| (5) findings, studies, or research conducted by or | 5 |
| under the auspices of federal government agencies and | 6 |
| nationally recognized federal research institutes, | 7 |
| including: | 8 |
| (a) the federal Agency for Healthcare Research and | 9 |
| Quality; | 10 |
| (b) the National Institutes of Health; | 11 |
| (c) the National Cancer Institute; | 12 |
| (d) the National Academy of Sciences; | 13 |
| (e) the Centers for Medicare & Medicaid Services; | 14 |
| (f) the federal Food and Drug Administration; and | 15 |
| (g) any national board recognized by the National | 16 |
| Institutes of Health for the purpose of evaluating the | 17 |
| medical value of health care services; or | 18 |
| (6) any other medical or scientific evidence that is | 19 |
| comparable to the sources listed in items (1) through (5). | 20 |
| "Protected health information" means health information | 21 |
| (i) that identifies an individual who is the subject of the | 22 |
| information; or (ii) with respect to which there is a | 23 |
| reasonable basis to believe that the information could be used | 24 |
| to identify an individual. | 25 |
| "Retrospective review" means a review of medical necessity | 26 |
| conducted after services have been provided to a patient, but |
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| does not include the review of a claim that is limited to an | 2 |
| evaluation of reimbursement levels, veracity of documentation, | 3 |
| accuracy of coding, or adjudication for payment. | 4 |
| "Utilization review" has the meaning provided by the | 5 |
| Managed Care Reform and Patient Rights Act. | 6 |
| "Utilization review organization" means a utilization | 7 |
| review program as defined in the Managed Care Reform and | 8 |
| Patient Rights Act. | 9 |
| Section 15. Applicability and scope. | 10 |
| (a) Except as provided in subsection (b) of this Section, | 11 |
| this Act shall apply to all health carriers. | 12 |
| (b) The provisions of this Act shall not apply to a policy | 13 |
| or certificate that provides coverage only for a specified | 14 |
| disease, specified accident or accident-only coverage, credit, | 15 |
| dental, disability income, hospital indemnity, long-term care | 16 |
| insurance as defined by Article XIXA of the Illinois Insurance | 17 |
| Code, vision care, or any other limited supplemental benefit; a | 18 |
| Medicare supplement policy of insurance as defined by the | 19 |
| Director by regulation; coverage under a plan through Medicare, | 20 |
| Medicaid, or the federal employees health benefits program; any | 21 |
| coverage issued under Chapter 55 of Title 10, U.S. Code and any | 22 |
| coverage issued as supplement to that coverage; any coverage | 23 |
| issued as supplemental to liability insurance, workers' | 24 |
| compensation, or similar insurance; automobile medical-payment | 25 |
| insurance or any insurance under which benefits are payable |
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| with or without regard to fault, whether written on a group | 2 |
| blanket or individual basis. | 3 |
| Section 20. Notice of right to external review. | 4 |
| (a) At the same time the health carrier sends written | 5 |
| notice of a covered person's right to appeal a coverage | 6 |
| decision upon an adverse determination or a final adverse | 7 |
| determination as provided by the Managed Care Reform and | 8 |
| Patient Rights Act, a health carrier shall notify a covered | 9 |
| person and a covered person's health care provider in writing | 10 |
| of the covered person's right to request an external review as | 11 |
| provided by this Act. The written notice required shall include | 12 |
| the following, or substantially equivalent, language: "We have | 13 |
| denied your request for the provision of or payment for a | 14 |
| health care service or course of treatment. You have the right | 15 |
| to have our decision reviewed by an independent review | 16 |
| organization not associated with us if our decision involved | 17 |
| making a judgment as to the medical necessity, appropriateness, | 18 |
| health care setting, level of care, or effectiveness of the | 19 |
| health care service or treatment you requested by submitting a | 20 |
| written request for an external review to us. Upon receipt of | 21 |
| your request an independent review organization registered | 22 |
| with the Department of Insurance will be assigned to review our | 23 |
| decision.". | 24 |
| (b) This subsection (b) shall apply to an expedited review | 25 |
| prior to a final adverse determination. In addition to the |
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| notice required in subsection (a), the health carrier shall | 2 |
| include a notice related to an adverse determination, a | 3 |
| statement informing the covered person all of the following: | 4 |
| (1) If the covered person has a medical condition where | 5 |
| the timeframe for completion of (A) an expedited internal | 6 |
| review of a grievance involving an adverse determination, | 7 |
| (B) a final adverse determination as set forth in the | 8 |
| Managed Care Reform and Patient Rights Act, or (C) a | 9 |
| standard external review as established in this Act, would | 10 |
| seriously jeopardize the life or health of the covered | 11 |
| person or would jeopardize the covered person's ability to | 12 |
| regain maximum function, then the covered person or the | 13 |
| covered person's authorized representative may file a | 14 |
| request for an expedited external review. | 15 |
| (2) The covered person or the covered person's | 16 |
| authorized representative may file a request for an | 17 |
| expedited external review at the same time the covered | 18 |
| person or the covered person's authorized representative | 19 |
| files a request for an expedited internal appeal involving | 20 |
| an adverse determination as set forth in the Managed Care | 21 |
| Reform and Patient Rights Act if the adverse determination | 22 |
| involves a denial of coverage based on a determination that | 23 |
| the recommended or requested health care service or | 24 |
| treatment is experimental or investigational and the | 25 |
| covered person's health care provider certifies in writing | 26 |
| that the recommended or requested health care service or |
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| treatment that is the subject of the adverse determination | 2 |
| would be significantly less effective if not promptly | 3 |
| initiated. The independent review organization assigned to | 4 |
| conduct the expedited external review will determine | 5 |
| whether the covered person shall be required to complete | 6 |
| the expedited review of the grievance prior to conducting | 7 |
| the expedited external review. | 8 |
| (3) If an adverse determination concerns a denial of | 9 |
| coverage based on a determination that the recommended or | 10 |
| requested health care service or treatment is experimental | 11 |
| or investigational and the covered person's health care | 12 |
| provider certifies in writing that the recommended or | 13 |
| requested health care service or treatment that is the | 14 |
| subject of the request would be significantly less | 15 |
| effective if not promptly initiated, then the covered | 16 |
| person or the covered person's authorized representative | 17 |
| may request an expedited external review. | 18 |
| (c) This subsection (c) shall apply to an expedited review | 19 |
| upon final adverse determination. In addition to the notice | 20 |
| required in subsection (a), the health carrier shall include a | 21 |
| notice related to a final adverse determination, a statement | 22 |
| informing the covered person all of the following: | 23 |
| (1) if the covered person has a medical condition where | 24 |
| the timeframe for completion of a standard external review | 25 |
| would seriously jeopardize the life or health of the | 26 |
| covered person or would jeopardize the covered person's |
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| ability to regain maximum function, then the covered person | 2 |
| or the covered person's authorized representative may file | 3 |
| a request for an expedited external review; or | 4 |
| (2) if a final adverse determination concerns an | 5 |
| admission, availability of care, continued stay, or health | 6 |
| care service for which the covered person received | 7 |
| emergency services, but has not been discharged from a | 8 |
| facility, then the covered person, or the covered person's | 9 |
| authorized representative, may request an expedited | 10 |
| external review; or | 11 |
| (3) if a final adverse determination concerns a denial | 12 |
| of coverage based on a determination that the recommended | 13 |
| or requested health care service or treatment is | 14 |
| experimental or investigational, and the covered person's | 15 |
| health care provider certifies in writing that the | 16 |
| recommended or requested health care service or treatment | 17 |
| that is the subject of the request would be significantly | 18 |
| less effective if not promptly initiated, then the covered | 19 |
| person or the covered person's authorized representative | 20 |
| may request an expedited external review. | 21 |
| (d) In addition to the information to be provided pursuant | 22 |
| to subsections (a), (b), and (c) of this Section, the health | 23 |
| carrier shall include a copy of the description of both the | 24 |
| required standard and expedited external review procedures. | 25 |
| The description shall highlight the external review procedures | 26 |
| that give the covered person or the covered person's authorized |
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| representative the opportunity to submit additional | 2 |
| information, including any forms used to process an external | 3 |
| review. | 4 |
| Section 25. Request for external review. A covered person | 5 |
| or the covered person's authorized representative may make a | 6 |
| request for a standard external or expedited external review of | 7 |
| an adverse determination or final adverse determination. | 8 |
| Requests under this Section shall be made directly to the | 9 |
| health carrier that made the adverse or final adverse | 10 |
| determination. All requests for external review shall be in | 11 |
| writing except for requests for expedited external reviews | 12 |
| which may me made orally. Health carriers must provide covered | 13 |
| persons with forms to request external reviews. | 14 |
| Section 30. Exhaustion of internal grievance process. | 15 |
| Except as provided in subsection (b) of Section 20, a | 16 |
| request for an external review shall not be made until the | 17 |
| covered person has exhausted the health carrier's internal | 18 |
| grievance process as set forth in the Managed Care Reform and | 19 |
| Patient Rights Act. A covered person shall also be considered | 20 |
| to have exhausted the health carrier's internal grievance | 21 |
| process for purposes of this section if: | 22 |
| (1) the covered person or the covered person's | 23 |
| authorized representative filed a request for an internal | 24 |
| review of an adverse determination pursuant to the Managed |
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| Care Reform and Patient Rights Act and has not received a | 2 |
| written decision on the request from the health carrier | 3 |
| within 15 days after receipt of the required information | 4 |
| but not more than 30 days after the request was filed by | 5 |
| the covered person or the covered person's authorized | 6 |
| representative, except to the extent the covered person or | 7 |
| the covered person's authorized representative requested | 8 |
| or agreed to a delay; however, a covered person or the | 9 |
| covered person's authorized representative may not make a | 10 |
| request for an external review of an adverse determination | 11 |
| involving a retrospective review determination until the | 12 |
| covered person has exhausted the health carrier's internal | 13 |
| grievance process; | 14 |
| (2) the covered person or the covered person's | 15 |
| authorized representative filed a request for an expedited | 16 |
| internal review of an adverse determination pursuant to the | 17 |
| Managed Care Reform and Patient Rights Act and has not | 18 |
| received a decision on request from the health carrier | 19 |
| within 48 hours, except to the extent the covered person or | 20 |
| the covered person's authorized representative requested | 21 |
| or agreed to a delay; or | 22 |
| (3) the health carrier agrees to waive the exhaustion | 23 |
| requirement. | 24 |
| Section 35. Standard external review. | 25 |
| (a) Within 4 months after the date of receipt of a notice |
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| of an adverse determination or final adverse determination, a | 2 |
| covered person or the covered person's authorized | 3 |
| representative may file a request for an external review with | 4 |
| the health carrier. | 5 |
| (b) Within 5 business days following the date of receipt of | 6 |
| the external review request, the health carrier shall complete | 7 |
| a preliminary review of the request to determine whether:
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| (1) the individual is or was a covered person in the | 9 |
| health benefit plan at the time the health care service was | 10 |
| requested or at the time the health care service was | 11 |
| provided; | 12 |
| (2) the health care service that is the subject of the | 13 |
| adverse determination or the final adverse determination | 14 |
| is a covered service under the covered person's health | 15 |
| benefit plan, but the health carrier has determined that | 16 |
| the health care service is not covered because it does not | 17 |
| meet the health carrier's requirements for medical | 18 |
| necessity, appropriateness, health care setting, level of | 19 |
| care, or effectiveness; | 20 |
| (3) the covered person has exhausted the health | 21 |
| carrier's internal grievance process as set forth in this | 22 |
| Act; | 23 |
| (4) for appeals relating to a determination based on | 24 |
| treatment being experimental or investigational, the | 25 |
| requested health care service or treatment that is the | 26 |
| subject of the adverse determination or final adverse |
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| determination is a covered benefit under the covered | 2 |
| person's health benefit plan except for the health | 3 |
| carrier's determination that the service or treatment is | 4 |
| experimental or investigational for a particular medical | 5 |
| condition and is not explicitly listed as an excluded | 6 |
| benefit under the covered person's health benefit plan with | 7 |
| the health carrier and that the covered person's health | 8 |
| care provider, who is a physician licensed to practice | 9 |
| medicine in all its branches, has certified that one of the | 10 |
| following situations is applicable: | 11 |
| (A) standard health care services or treatments | 12 |
| have not been effective in improving the condition of | 13 |
| the covered person; | 14 |
| (B) standard health care services or treatments | 15 |
| are not medically appropriate for the covered person; | 16 |
| (C) there is no available standard health care | 17 |
| service or treatment covered by the health carrier that | 18 |
| is more beneficial than the recommended or requested | 19 |
| health care service or treatment;
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| (D) the health care service or treatment is likely | 21 |
| to be more beneficial to the covered person, in the | 22 |
| health care provider's opinion, than any available | 23 |
| standard health care services or treatments; or | 24 |
| (E) that scientifically valid studies using | 25 |
| accepted protocols demonstrate that the health care | 26 |
| service or treatment requested is likely to be more |
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| beneficial to the covered person than any available | 2 |
| standard health care services or treatments; and | 3 |
| (5) the covered person has provided all the information | 4 |
| and forms required to process an external review, as | 5 |
| specified in this Act. | 6 |
| (c) Within one business day after completion of the | 7 |
| preliminary review, the health carrier shall notify the covered | 8 |
| person and, if applicable, the covered person's authorized | 9 |
| representative in writing whether the request is complete and | 10 |
| eligible for external review. If the request: | 11 |
| (1) is not complete, the health carrier shall inform | 12 |
| the covered person and, if applicable, the covered person's | 13 |
| authorized representative in writing and include in the | 14 |
| notice what information or materials are required by this | 15 |
| Act to make the request complete; or | 16 |
| (2) is not eligible for external review, the health | 17 |
| carrier shall inform the covered person and, if applicable, | 18 |
| the covered person's authorized representative in writing | 19 |
| and include in the notice the reasons for its | 20 |
| ineligibility.
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| The notice of initial determination of ineligibility shall | 22 |
| include a statement informing the covered person and, if | 23 |
| applicable, the covered person's authorized representative | 24 |
| that a health carrier's initial determination that the external | 25 |
| review request is ineligible for review may be appealed to the | 26 |
| Director by filing a complaint with the Director. |
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| Notwithstanding a health carrier's initial determination | 2 |
| that the request is ineligible for external review, the | 3 |
| Director may determine that a request is eligible for external | 4 |
| review and require that it be referred for external review. In | 5 |
| making such determination, the Director's decision shall be in | 6 |
| accordance with the terms of the covered person's health | 7 |
| benefit plan and shall be subject to all applicable provisions | 8 |
| of this Act. | 9 |
| (d) Whenever a request is eligible for external review the | 10 |
| health carrier shall, within 5 business days: | 11 |
| (1) assign an independent review organization from the | 12 |
| list of approved independent review organizations compiled | 13 |
| and maintained by the Director; and | 14 |
| (2) notify in writing the covered person and, if | 15 |
| applicable, the covered person's authorized representative | 16 |
| of the request's eligibility and acceptance for external | 17 |
| review and the name of the independent review organization. | 18 |
| The health carrier shall include in the notice provided to | 19 |
| the covered person and, if applicable, the covered person's | 20 |
| authorized representative a statement that the covered person | 21 |
| or the covered person's authorized representative may, within 5 | 22 |
| business days following the date of receipt of the notice | 23 |
| provided pursuant to item (2) of this subsection (d), submit in | 24 |
| writing to the assigned independent review organization | 25 |
| additional information that the independent review | 26 |
| organization shall consider when conducting the external |
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| review. The independent review organization is not required to, | 2 |
| but may, accept and consider additional information submitted | 3 |
| after 5 business days. | 4 |
| (e) The assignment of an approved independent review | 5 |
| organization to conduct an external review in accordance with | 6 |
| this Section shall be made from those approved independent | 7 |
| review organizations qualified to conduct external review as | 8 |
| required by Sections 50 and 55 of this Act. | 9 |
| (f) Upon assignment of an independent review organization, | 10 |
| the health carrier or its designee utilization review | 11 |
| organization shall, within 5 business days, provide to the | 12 |
| assigned independent review organization the documents and any | 13 |
| information considered in making the adverse determination or | 14 |
| final adverse determination; in such cases, the following | 15 |
| provisions shall apply: | 16 |
| (1) Except as provided in item (2) of this subsection | 17 |
| (f), failure by the health carrier or its utilization | 18 |
| review organization to provide the documents and | 19 |
| information within the specified time frame shall not delay | 20 |
| the conduct of the external review. | 21 |
| (2) If the health carrier or its utilization review | 22 |
| organization fails to provide the documents and | 23 |
| information within the specified time frame, the assigned | 24 |
| independent review organization may terminate the external | 25 |
| review and make a decision to reverse the adverse | 26 |
| determination or final adverse determination. |
|
|
|
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| (3) Within one business day after making the decision | 2 |
| to terminate the external review and make a decision to | 3 |
| reverse the adverse determination or final adverse | 4 |
| determination under item (2) of this subsection (f), the | 5 |
| independent review organization shall notify the health | 6 |
| carrier, the covered person and, if applicable, the covered | 7 |
| person's authorized representative, of its decision to | 8 |
| reverse the adverse determination. | 9 |
| (g) Upon receipt of the information from the health carrier | 10 |
| or its utilization review organization, the assigned | 11 |
| independent review organization shall review all of the | 12 |
| information and documents and any other information submitted | 13 |
| in writing to the independent review organization by the | 14 |
| covered person and the covered person's authorized | 15 |
| representative. | 16 |
| (h) Upon receipt of any information submitted by the | 17 |
| covered person or the covered person's authorized | 18 |
| representative, the independent review organization shall | 19 |
| forward the information to the health carrier within 1 business | 20 |
| day. | 21 |
| (1) Upon receipt of the information, if any, the health | 22 |
| carrier may reconsider its adverse determination or final | 23 |
| adverse determination that is the subject of the external | 24 |
| review.
| 25 |
| (2) Reconsideration by the health carrier of its | 26 |
| adverse determination or final adverse determination shall |
|
|
|
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| 1 |
| not delay or terminate the external review.
| 2 |
| (3) The external review may only be terminated if the | 3 |
| health carrier decides, upon completion of its | 4 |
| reconsideration, to reverse its adverse determination or | 5 |
| final adverse determination and provide coverage or | 6 |
| payment for the health care service that is the subject of | 7 |
| the adverse determination or final adverse determination. | 8 |
| In such cases, the following provisions shall apply: | 9 |
| (A) Within one business day after making the | 10 |
| decision to reverse its adverse determination or final | 11 |
| adverse determination, the health carrier shall notify | 12 |
| the covered person and if applicable, the covered | 13 |
| person's authorized representative, and the assigned | 14 |
| independent review organization in writing of its | 15 |
| decision. | 16 |
| (B) Upon notice from the health carrier that the | 17 |
| health carrier has made a decision to reverse its | 18 |
| adverse determination or final adverse determination, | 19 |
| the assigned independent review organization shall | 20 |
| terminate the external review. | 21 |
| (i) In addition to the documents and information provided | 22 |
| by the health carrier or its utilization review organization | 23 |
| and the covered person and the covered person's authorized | 24 |
| representative, if any, the independent review organization, | 25 |
| to the extent the information or documents are available and | 26 |
| the independent review organization considers them |
|
|
|
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| 1 |
| appropriate, shall consider the following in reaching a | 2 |
| decision: | 3 |
| (1) the covered person's pertinent medical records; | 4 |
| (2) the covered person's health care provider's | 5 |
| recommendation; | 6 |
| (3) consulting reports from appropriate health care | 7 |
| providers and other documents submitted by the health | 8 |
| carrier, the covered person, the covered person's | 9 |
| authorized representative, or the covered person's | 10 |
| treating provider; | 11 |
| (4) the terms of coverage under the covered person's | 12 |
| health benefit plan with the health carrier to ensure that | 13 |
| the independent review organization's decision is not | 14 |
| contrary to the terms of coverage under the covered | 15 |
| person's health benefit plan with the health carrier; | 16 |
| (5) the most appropriate practice guidelines, which | 17 |
| shall include applicable evidence-based standards and may | 18 |
| include any other practice guidelines developed by the | 19 |
| federal government, national or professional medical | 20 |
| societies, boards, and associations; | 21 |
| (6) any applicable clinical review criteria developed | 22 |
| and used by the health carrier or its designee utilization | 23 |
| review organization; and | 24 |
| (7) the opinion of the independent review | 25 |
| organization's clinical reviewer or reviewers after | 26 |
| considering items (1) through (6) of this subsection (i) to |
|
|
|
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| the extent the information or documents are available and | 2 |
| the clinical reviewer or reviewers considers the | 3 |
| information or documents appropriate; and | 4 |
| (8) for a denial of coverage based on a determination | 5 |
| that the health care service or treatment recommended or | 6 |
| requested is experimental or investigational, whether and | 7 |
| to what extent: | 8 |
| (A) the recommended or requested health care | 9 |
| service or treatment has been approved by the federal | 10 |
| Food and Drug Administration, if applicable, for the | 11 |
| condition; | 12 |
| (B) medical or scientific evidence or | 13 |
| evidence-based standards demonstrate that the expected | 14 |
| benefits of the recommended or requested health care | 15 |
| service or treatment is more likely than not to be | 16 |
| beneficial to the covered person than any available | 17 |
| standard health care service or treatment and the | 18 |
| adverse risks of the recommended or requested health | 19 |
| care service or treatment would not be substantially | 20 |
| increased over those of available standard health care | 21 |
| services or treatments; or | 22 |
| (C) the terms of coverage under the covered | 23 |
| person's health benefit plan with the health carrier to | 24 |
| ensure that the health care service or treatment that | 25 |
| is the subject of the opinion is experimental or | 26 |
| investigational would otherwise be covered under the |
|
|
|
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| terms of coverage of the covered person's health | 2 |
| benefit plan with the health carrier. | 3 |
| (j) Within 5 days after the date of receipt of all | 4 |
| necessary information, the assigned independent review | 5 |
| organization shall provide written notice of its decision to | 6 |
| uphold or reverse the adverse determination or the final | 7 |
| adverse determination to the health carrier, the covered person | 8 |
| and, if applicable, the covered person's authorized | 9 |
| representative. In reaching a decision, the assigned | 10 |
| independent review organization is not bound by any claim | 11 |
| determinations reached prior to the submission of information | 12 |
| the independent review organization. In such cases, the | 13 |
| following provisions shall apply: | 14 |
| (1) The independent review organization shall include | 15 |
| in the notice: | 16 |
| (A) a general description of the reason for the | 17 |
| request for external review; | 18 |
| (B) the date the independent review organization | 19 |
| received the assignment from the health carrier to | 20 |
| conduct the external review; | 21 |
| (C) the time period during which the external | 22 |
| review was conducted; | 23 |
| (D) references to the evidence or documentation, | 24 |
| including the evidence-based standards, considered in | 25 |
| reaching its decision; | 26 |
| (E) the date of its decision; and |
|
|
|
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| (F) the principal reason or reasons for its | 2 |
| decision, including what applicable, if any, | 3 |
| evidence-based standards that were a basis for its | 4 |
| decision.
| 5 |
| (2) For reviews of experimental or investigational | 6 |
| treatments, the notice shall include the following | 7 |
| information: | 8 |
| (A) a description of the covered person's medical | 9 |
| condition; | 10 |
| (B) a description of the indicators relevant to | 11 |
| whether there is sufficient evidence to demonstrate | 12 |
| that the recommended or requested health care service | 13 |
| or treatment is more likely than not to be more | 14 |
| beneficial to the covered person than any available | 15 |
| standard health care services or treatments and the | 16 |
| adverse risks of the recommended or requested health | 17 |
| care service or treatment would not be substantially | 18 |
| increased over those of available standard health care | 19 |
| services or treatments; | 20 |
| (C) a description and analysis of any medical or | 21 |
| scientific evidence considered in reaching the | 22 |
| opinion; | 23 |
| (D) a description and analysis of any | 24 |
| evidence-based standards; and | 25 |
| (E) whether the recommended or requested health | 26 |
| care service or treatment has been approved by the |
|
|
|
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| 1 |
| federal Food and Drug Administration, for the | 2 |
| condition; | 3 |
| (F) whether medical or scientific evidence or | 4 |
| evidence-based standards demonstrate that the expected | 5 |
| benefits of the recommended or requested health care | 6 |
| service or treatment is more likely than not to be more | 7 |
| beneficial to the covered person than any available | 8 |
| standard health care service or treatment and the | 9 |
| adverse risks of the recommended or requested health | 10 |
| care service or treatment would not be substantially | 11 |
| increased over those of available standard health care | 12 |
| services or treatments; and | 13 |
| (G) the written opinion of the clinical reviewer, | 14 |
| including the reviewer's recommendation as to whether | 15 |
| the recommended or requested health care service or | 16 |
| treatment should be covered and the rationale for the | 17 |
| reviewer's recommendation. | 18 |
| (3) In reaching a decision, the assigned independent | 19 |
| review organization is not bound by any decisions or | 20 |
| conclusions reached during the health carrier's | 21 |
| utilization review process or the health carrier's | 22 |
| internal grievance or appeals process. | 23 |
| (4) Upon receipt of a notice of a decision reversing | 24 |
| the adverse determination or final adverse determination, | 25 |
| the health carrier immediately shall approve the coverage | 26 |
| that was the subject of the adverse determination or final |
|
|
|
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| 1 |
| adverse determination. | 2 |
| Section 40. Expedited external review. | 3 |
| (a) A covered person or a covered person's authorized | 4 |
| representative may file a request for an expedited external | 5 |
| review with the health carrier either orally or in writing: | 6 |
| (1) immediately after the date of receipt of a notice | 7 |
| prior to a final adverse determination as provided by | 8 |
| subsection (b) of Section 20 of this Act; | 9 |
| (2) immediately after the date of receipt of a notice a | 10 |
| final adverse determination as provided by subsection (c) | 11 |
| of Section 20 of this Act; or | 12 |
| (3) if a health carrier fails to provide a decision on | 13 |
| request for an expedited internal appeal within 48 hours as | 14 |
| provided by item (2) of Section 30 of this Act. | 15 |
| (b) Immediately upon receipt of the request for an | 16 |
| expedited external review as provided under subsections (b) and | 17 |
| (c) of Section 20, the health carrier shall determine whether | 18 |
| the request meets the reviewability requirements set forth in | 19 |
| items (1), (2), and (4) of subsection (b) of Section 35. In | 20 |
| such cases, the following provisions shall apply: | 21 |
| (1) The health carrier shall immediately notify the | 22 |
| covered person and, if applicable, the covered person's | 23 |
| authorized representative of its eligibility | 24 |
| determination. | 25 |
| (2) The notice of initial determination shall include a |
|
|
|
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| 1 |
| statement informing the covered person and, if applicable, | 2 |
| the covered person's authorized representative that a | 3 |
| health carrier's initial determination that an external | 4 |
| review request is ineligible for review may be appealed to | 5 |
| the Director. | 6 |
| (3) The Director may determine that a request is | 7 |
| eligible for expedited external review notwithstanding a | 8 |
| health carrier's initial determination that the request is | 9 |
| ineligible and require that it be referred for external | 10 |
| review. | 11 |
| (4) In making a determination under item (3) of this | 12 |
| subsection (b), the Director's decision shall be made in | 13 |
| accordance with the terms of the covered person's health | 14 |
| benefit plan and shall be subject to all applicable | 15 |
| provisions of this Act. | 16 |
| (c) Upon determining that a request meets the requirements | 17 |
| of subsections (b) and (c) of Section 20, the health
carrier | 18 |
| shall immediately assign an independent review organization | 19 |
| from the list of approved independent review organizations | 20 |
| compiled and maintained by the Director to conduct the | 21 |
| expedited review. In such cases, the following provisions shall | 22 |
| apply: | 23 |
| (1) The assignment of an approved independent review | 24 |
| organization to conduct an external review in accordance | 25 |
| with this Section shall be made from those approved | 26 |
| independent review organizations qualified to conduct |
|
|
|
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| 1 |
| external review as required by Sections 50 and 55 of this | 2 |
| Act.
| 3 |
| (2) Immediately upon assigning an independent review | 4 |
| organization to perform an expedited external review, but | 5 |
| in no case more than 24 hours after assigning the | 6 |
| independent review organization, the health carrier or its | 7 |
| designee utilization review organization shall provide or | 8 |
| transmit all necessary documents and information | 9 |
| considered in making the final adverse determination to the | 10 |
| assigned independent review organization electronically or | 11 |
| by telephone or facsimile or any other available | 12 |
| expeditious method. | 13 |
| (3) If the health carrier or its utilization review | 14 |
| organization fails to provide the documents and | 15 |
| information within the specified timeframe, the assigned | 16 |
| independent review organization may terminate the external | 17 |
| review and make a decision to reverse the adverse | 18 |
| determination or final adverse determination. | 19 |
| (4) Within one business day after making the decision | 20 |
| to terminate the external review and make a decision to | 21 |
| reverse the adverse determination or final adverse | 22 |
| determination under item (2) of this subsection (b), the | 23 |
| independent review organization shall notify the health | 24 |
| carrier, the covered person and, if applicable, the covered | 25 |
| person's authorized representative of its decision to | 26 |
| reverse the adverse determination.
|
|
|
|
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| 1 |
| (d) In addition to the documents and information provided | 2 |
| by the health carrier or its utilization review organization | 3 |
| and any documents and information provided by the covered | 4 |
| person and the covered person's authorized representative, the | 5 |
| independent review organization shall consider information as | 6 |
| required by subsection (i) of Section 35 of this Act in | 7 |
| reaching a decision. | 8 |
| (e) As expeditiously as the covered person's medical | 9 |
| condition or circumstances requires, but in no event more than | 10 |
| 24 hours after the receipt of all pertinent information, the | 11 |
| assigned independent review organization shall: | 12 |
| (1) make a decision to uphold or reverse the final | 13 |
| adverse determination; and | 14 |
| (2) notify the health carrier, the covered person, the | 15 |
| covered person's health care provider, and if applicable, | 16 |
| the covered person's authorized representative, of the | 17 |
| decision. | 18 |
| (f) In reaching a decision, the assigned independent review | 19 |
| organization is not bound by any decisions or conclusions | 20 |
| reached during the health carrier's utilization review process | 21 |
| or the health carrier's internal grievance process as set forth | 22 |
| in the Managed Care Reform and Patient Rights Act.
| 23 |
| (g) Upon receipt of notice of a decision reversing the | 24 |
| final adverse determination, the health carrier shall | 25 |
| immediately approve the coverage that was the subject of the | 26 |
| final adverse determination. |
|
|
|
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| 1 |
| (h) Within 48 hours after the date of providing the notice | 2 |
| required in item (2) of subsection (d), the assigned | 3 |
| independent review organization shall provide written | 4 |
| confirmation of the decision to the health carrier, the covered | 5 |
| person, and if applicable, the covered person's authorized | 6 |
| representative including the information set forth in | 7 |
| subsection (j) of Section 35 of this Act as applicable. | 8 |
| (i) An expedited external review may not be provided for | 9 |
| retrospective adverse or final adverse determinations. | 10 |
| Section 45. Binding nature of external review decision. An | 11 |
| external review decision is binding on the health carrier. An | 12 |
| external review decision is binding on the covered person | 13 |
| except to the extent the covered person has other remedies | 14 |
| available under applicable federal or State law. A covered | 15 |
| person or the covered person's authorized representative may | 16 |
| not file a subsequent request for external review involving the | 17 |
| same adverse determination or final adverse determination for | 18 |
| which the covered person has already received an external | 19 |
| review decision pursuant to this Act.
| 20 |
| Section 50. Approval of independent review organizations. | 21 |
| (a) The Director shall approve independent review | 22 |
| organizations eligible to be assigned to conduct external | 23 |
| reviews under this Act. | 24 |
| (b) In order to be eligible for approval by the Director |
|
|
|
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| 1 |
| under this Section to conduct external reviews under this Act | 2 |
| an independent review organization:
| 3 |
| (1) except as otherwise provided in this Section, shall | 4 |
| be accredited by a nationally recognized private | 5 |
| accrediting entity that the Director has determined has | 6 |
| independent review organization accreditation standards | 7 |
| that are equivalent to or exceed the minimum qualifications | 8 |
| for independent review; and | 9 |
| (2) shall submit an application for approval in | 10 |
| accordance with subsection (d) of this Section.
| 11 |
| (c) The Director shall develop an application form for | 12 |
| initially approving and for reapproving independent review | 13 |
| organizations to conduct external reviews. | 14 |
| (d) Any independent review organization wishing to be | 15 |
| approved to conduct external reviews under this Act shall | 16 |
| submit the application form and include with the form all | 17 |
| documentation and information necessary for the Director to | 18 |
| determine if the independent review organization satisfies the | 19 |
| minimum qualifications established under this Act.
The | 20 |
| Director may: | 21 |
| (1) approve independent review organizations that are | 22 |
| not accredited by a nationally recognized private | 23 |
| accrediting entity if there are no acceptable nationally | 24 |
| recognized private accrediting entities providing | 25 |
| independent review organization accreditation; and | 26 |
| (2) by rule establish an application fee that |
|
|
|
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| 1 |
| independent review organizations shall submit to the | 2 |
| Director with an application for approval and renewing.
| 3 |
| (e) An approval is effective for 2 years, unless the | 4 |
| Director determines before its expiration that the independent | 5 |
| review organization is not satisfying the minimum | 6 |
| qualifications established under this Act. | 7 |
| (f) Whenever the Director determines that an independent | 8 |
| review organization has lost its accreditation or no longer | 9 |
| satisfies the minimum requirements established under this Act, | 10 |
| the Director shall terminate the approval of the independent | 11 |
| review organization and remove the independent review | 12 |
| organization from the list of independent review organizations | 13 |
| approved to conduct external reviews under this Act that is | 14 |
| maintained by the Director. | 15 |
| (g) The Director shall maintain and periodically update a | 16 |
| list of approved independent review organizations. | 17 |
| (h) The Director may promulgate regulations to carry out | 18 |
| the provisions of this Section. | 19 |
| Section 55. Minimum qualifications for independent review | 20 |
| organizations.
| 21 |
| (a) To be approved to conduct external reviews, an | 22 |
| independent review organization shall have and maintain | 23 |
| written policies and procedures that govern all aspects of both | 24 |
| the standard external review process and the expedited external | 25 |
| review process set forth in this Act that include, at a |
|
|
|
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| 1 |
| minimum: | 2 |
| (1) a quality assurance mechanism that ensures that: | 3 |
| (A) external reviews are conducted within the | 4 |
| specified timeframes and required notices are provided | 5 |
| in a timely manner; | 6 |
| (B) selection of qualified and impartial clinical | 7 |
| reviewers to conduct external reviews on behalf of the | 8 |
| independent review organization and suitable matching | 9 |
| of reviewers to specific cases and that the independent | 10 |
| review organization employs or contracts with an | 11 |
| adequate number of clinical reviewers to meet this | 12 |
| objective; | 13 |
| (C) for adverse determinations involving | 14 |
| experimental or investigational treatments, in | 15 |
| assigning clinical reviewers, the independent review | 16 |
| organization selects physicians or other health care | 17 |
| professionals who, through clinical experience in the | 18 |
| past 3 years, are experts in the treatment of the | 19 |
| covered person's condition and knowledgeable about the | 20 |
| recommended or requested health care service or | 21 |
| treatment; | 22 |
| (D) the health carrier, the covered person, and the | 23 |
| covered person's authorized representative shall not | 24 |
| choose or control the choice of the physicians or other | 25 |
| health care professionals to be selected to conduct the | 26 |
| external review; |
|
|
|
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| (E) confidentiality of medical and treatment | 2 |
| records and clinical review criteria; and | 3 |
| (F) any person employed by or under contract with | 4 |
| the independent review organization adheres to the | 5 |
| requirements of this Act; | 6 |
| (2) a toll-free telephone service operating on a | 7 |
| 24-hour-day, 7-day-a-week basis that accepts, receives, | 8 |
| and records information related to external reviews and | 9 |
| provides appropriate instructions; and | 10 |
| (3) an agreement to maintain and provide to the | 11 |
| Director the information set out in Section 70 of this Act. | 12 |
| (b) All clinical reviewers assigned by an independent | 13 |
| review organization to conduct external reviews shall be | 14 |
| physicians or other appropriate health care providers who meet | 15 |
| the following minimum qualifications:
| 16 |
| (1) be an expert in the treatment of the covered | 17 |
| person's medical condition that is the subject of the | 18 |
| external review; | 19 |
| (2) be knowledgeable about the recommended health care | 20 |
| service or treatment through recent or current actual | 21 |
| clinical experience treating patients with the same or | 22 |
| similar medical condition of the covered person; | 23 |
| (3) hold a non-restricted license in a state of the | 24 |
| United States and, for physicians, a current certification | 25 |
| by a recognized American medical specialty board in the | 26 |
| area or areas appropriate to the subject of the external |
|
|
|
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| 1 |
| review; and | 2 |
| (4) have no history of disciplinary actions or | 3 |
| sanctions, including loss of staff privileges or | 4 |
| participation restrictions, that have been taken or are | 5 |
| pending by any hospital, governmental agency or unit, or | 6 |
| regulatory body that raise a substantial question as to the | 7 |
| clinical reviewer's physical, mental, or professional | 8 |
| competence or moral character. | 9 |
| (c) In addition to the requirements set forth in subsection | 10 |
| (a), an independent review organization may not own or control, | 11 |
| be a subsidiary of, or in any way be owned, or controlled by, | 12 |
| or exercise control with a health benefit plan, a national, | 13 |
| State, or local trade association of health benefit plans, or a | 14 |
| national, State, or local trade association of health care | 15 |
| providers. | 16 |
| (d) Conflicts of interest prohibited.
In addition to the | 17 |
| requirements set forth in subsections (a), (b), and (c) of this | 18 |
| Section, to be approved pursuant to this Act to conduct an | 19 |
| external review of a specified case, neither the independent | 20 |
| review organization selected to conduct the external review nor | 21 |
| any clinical reviewer assigned by the independent organization | 22 |
| to conduct the external review may have a material | 23 |
| professional, familial or financial conflict of interest with | 24 |
| any of the following: | 25 |
| (1) the health carrier that is the subject of the | 26 |
| external review; |
|
|
|
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| 1 |
| (2) the covered person whose treatment is the subject | 2 |
| of the external review or the covered person's authorized | 3 |
| representative; | 4 |
| (3) any officer, director or management employee of the | 5 |
| health carrier that is the subject of the external review; | 6 |
| (4) the health care provider, the health care | 7 |
| provider's medical group or independent practice | 8 |
| association recommending the health care service or | 9 |
| treatment that is the subject of the external review; | 10 |
| (5) the facility at which the recommended health care | 11 |
| service or treatment would be provided; or | 12 |
| (6) the developer or manufacturer of the principal | 13 |
| drug, device, procedure, or other therapy being | 14 |
| recommended for the covered person whose treatment is the | 15 |
| subject of the external review.
| 16 |
| (e) An independent review organization that is accredited | 17 |
| by a nationally recognized private accrediting entity that has | 18 |
| independent review accreditation standards that the Director | 19 |
| has determined are equivalent to or exceed the minimum | 20 |
| qualifications of this Section shall be presumed to be in | 21 |
| compliance with this Section and shall be eligible for approval | 22 |
| under this Act. | 23 |
| (f) An independent review organization shall be unbiased. | 24 |
| An independent review organization shall establish and | 25 |
| maintain written procedures to ensure that it is unbiased in | 26 |
| addition to any other procedures required under this Section. |
|
|
|
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| 1 |
| (g) Nothing in this Act precludes or shall be interpreted | 2 |
| to preclude a health carrier from contracting with approved | 3 |
| independent review organizations to conduct external reviews | 4 |
| assigned to it from such health carrier. | 5 |
| Section 60. Hold harmless for independent review | 6 |
| organizations. No independent review organization or clinical | 7 |
| reviewer working on behalf of an independent review | 8 |
| organization or an employee, agent or contractor of an | 9 |
| independent review organization shall be liable for damages to | 10 |
| any person for any opinions rendered or acts or omissions | 11 |
| performed within the scope of the organization's or person's | 12 |
| duties under the law during or upon completion of an external | 13 |
| review conducted pursuant to this Act, unless the opinion was | 14 |
| rendered or act or omission performed in bad faith or involved | 15 |
| gross negligence. | 16 |
| Section 65. External review reporting requirements. | 17 |
| (a) Each health carrier shall maintain written records in | 18 |
| the aggregate on all requests for external review for each | 19 |
| calendar year and submit a report to the Director in the format | 20 |
| specified by the Director by March 1 of each year. | 21 |
| (b) The report shall include in the aggregate:
| 22 |
| (1) the total number of requests for external review; | 23 |
| (2) the total number of requests for expedited external | 24 |
| review;
|
|
|
|
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| 1 |
| (3) the total number of requests for external review | 2 |
| denied; | 3 |
| (4) the number of requests for external review | 4 |
| resolved, including: | 5 |
| (A) the number of requests for external review | 6 |
| resolved upholding the adverse determination or final | 7 |
| adverse determination; | 8 |
| (B) the number of requests for external review | 9 |
| resolved reversing the adverse determination or final | 10 |
| adverse determination; | 11 |
| (C) the number of requests for expedited external | 12 |
| review resolved upholding the adverse determination or | 13 |
| final adverse determination; and | 14 |
| (D) the number of requests for expedited external | 15 |
| review resolved reversing the adverse determination or | 16 |
| final adverse determination; | 17 |
| (5) the average length of time for resolution for an | 18 |
| external review; | 19 |
| (6) the average length of time for resolution for an | 20 |
| expedited external review; | 21 |
| (7) a summary of the types of coverages or cases for | 22 |
| which an external review was sought, as specified below:
| 23 |
| (A) denial of care or treatment (dissatisfaction | 24 |
| regarding prospective non-authorization of a request | 25 |
| for care or treatment recommended by a provider | 26 |
| excluding diagnostic procedures and referral requests; |
|
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| 1 |
| partial approvals and care terminations are also | 2 |
| considered to be denials); | 3 |
| (B) denial of diagnostic procedure | 4 |
| (dissatisfaction regarding prospective | 5 |
| non-authorization of a request for a diagnostic | 6 |
| procedure recommended by a provider; partial approvals | 7 |
| are also considered to be denials); | 8 |
| (C) denial of referral request (dissatisfaction | 9 |
| regarding non-authorization of a request for a | 10 |
| referral to another provider recommended by a PCP); | 11 |
| (D) claims and utilization review (dissatisfaction | 12 |
| regarding the concurrent or retrospective evaluation | 13 |
| of the coverage, medical necessity, efficiency or | 14 |
| appropriateness of health care services or treatment | 15 |
| plans; prospective "Denials of care or treatment", | 16 |
| "Denials of diagnostic procedures" and "Denials of | 17 |
| referral requests" should not be classified in this | 18 |
| category, but the appropriate one above);
| 19 |
| (8) the number of external reviews that were terminated | 20 |
| as the result of a reconsideration by the health carrier of | 21 |
| its adverse determination or final adverse determination | 22 |
| after the receipt of additional information from the | 23 |
| covered person or the covered person's authorized | 24 |
| representative; and | 25 |
| (9) any other information the Director may request or | 26 |
| require.
|
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| Section 70. Funding of external review. The health carrier | 2 |
| shall be solely responsible for paying the cost of external | 3 |
| reviews conducted by independent review organizations. | 4 |
| Section 75. Disclosure requirements. | 5 |
| (a) Each health carrier shall include a description of the | 6 |
| external review procedures in, or attached to, the policy, | 7 |
| certificate, membership booklet, and outline of coverage or | 8 |
| other evidence of coverage it provides to covered persons. | 9 |
| (b) The description required under subsection (a) of this | 10 |
| Section shall include a statement that informs the covered | 11 |
| person of the right of the covered person to file a request for | 12 |
| an external review of an adverse determination or final adverse | 13 |
| determination with the health carrier. The statement shall | 14 |
| explain that external review is available when the adverse | 15 |
| determination or final adverse determination involves an issue | 16 |
| of medical necessity, appropriateness, health care setting, | 17 |
| level of care, or effectiveness. The statement shall include | 18 |
| the toll-free telephone number and address of the Office of | 19 |
| Consumer Health Insurance within the Department of Insurance.
| 20 |
| Section 90. The Illinois Insurance Code is amended by | 21 |
| changing Section 155.36 and by adding Sections 359b and 359c as | 22 |
| follows:
|
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| (215 ILCS 5/155.36)
| 2 |
| Sec. 155.36. Managed Care Reform and Patient Rights Act. | 3 |
| Insurance
companies that transact the kinds of insurance | 4 |
| authorized under Class 1(b) or
Class 2(a) of Section 4 of this | 5 |
| Code shall comply
with Sections 45 and Section 85 and the | 6 |
| definition of the term "emergency medical
condition" in Section
| 7 |
| 10 of the Managed Care Reform and Patient Rights Act.
| 8 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 9 |
| (215 ILCS 5/359b new)
| 10 |
| Sec. 359b. Committee to create a uniform small employer | 11 |
| group-health status questionnaire and individual health | 12 |
| statement. | 13 |
| (a) For the purposes of this Section: | 14 |
| "Employee health-status questionnaire" means a | 15 |
| questionnaire that poses questions about an individual | 16 |
| employee's or covered dependent's health history and that is to | 17 |
| be completed by the individual employee or covered dependent of | 18 |
| a small employer that seeks health insurance coverage from a | 19 |
| small employer carrier. | 20 |
| "Health benefit plan", "small employer", and "small | 21 |
| employer carrier" shall have the meaning given the terms in the | 22 |
| Small Employer Health Insurance Rating Act. | 23 |
| "Individual health insurance coverage" and "individual | 24 |
| market" shall have the meaning given the terms in the Illinois | 25 |
| Health Insurance Portability and Accountability Act. |
|
|
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| (b) A committee is established in the Department consisting | 2 |
| of 11 members, including the Director or the Director's | 3 |
| designee, who are appointed by the Director. The Director shall | 4 |
| appoint to the committee 5 representatives as recommended by | 5 |
| the Illinois Insurance Association, Illinois Life Insurance | 6 |
| Council, Professional Independent Insurance Agents of | 7 |
| Illinois, Illinois Association of Health Underwriters, | 8 |
| Illinois Chamber of Commerce, Illinois Manufacturers | 9 |
| Association, Illinois Retail Merchants Association, and | 10 |
| National Federation of Independent Businesses and 5 consumer | 11 |
| representatives. The Director or the Director's designee shall | 12 |
| serve as chairperson of the committee. | 13 |
| (c) The committee shall develop a uniform employee | 14 |
| health-status questionnaire to simplify the health insurance | 15 |
| application process for small employers. The committee shall | 16 |
| study employee-health status questionnaires currently used by | 17 |
| major small employer carriers in this State and consolidate the | 18 |
| questionnaires into a uniform questionnaire. The questionnaire | 19 |
| shall be designed to permit its use both as a written document | 20 |
| and through electronic or other alternative delivery formats. | 21 |
| A uniform employee health-status questionnaire shall allow | 22 |
| small employers that are required to provide information | 23 |
| regarding their employees to a small employer carrier when | 24 |
| applying for a small employer group health insurance policy to | 25 |
| use a standardized questionnaire that small employer carriers | 26 |
| shall be required to use. The development of the uniform |
|
|
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| employee health-status questionnaire is intended to relieve | 2 |
| small employers of the burden of completing separate | 3 |
| application forms for each small employer carrier with which | 4 |
| the employer applies for insurance or from which the employer | 5 |
| seeks information regarding such matters as rates, coverage, | 6 |
| and availability. The use of the uniform employee health-status | 7 |
| questionnaire by small employer carriers and small employers | 8 |
| shall be mandatory. | 9 |
| (d) On or before July 1, 2010, the committee shall develop | 10 |
| the uniform employee health-status questionnaire for adoption | 11 |
| by the Department. Beginning January 1, 2011, a small employer | 12 |
| carrier shall use the questionnaire for all small employer | 13 |
| groups for which it requires employees and their covered | 14 |
| dependents to complete questionnaires. | 15 |
| (e) The Director, as needed, may reconvene the committee to | 16 |
| consider whether changes are necessary to the uniform employee | 17 |
| health status questionnaire. If the committee determines that | 18 |
| changes to the questionnaire are necessary, then the Director | 19 |
| may adopt revisions to the questionnaire as recommended by the | 20 |
| committee. Small employer carriers shall use the revised | 21 |
| questionnaire beginning 90 days after the Director adopts any | 22 |
| revision. | 23 |
| (f) Nothing in this Section shall be construed to limit or | 24 |
| restrict a small employer carrier's ability to appropriately | 25 |
| rate risk under a small employer health benefit plan. | 26 |
| (g) On or before July 1, 2010, the committee shall develop |
|
|
|
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| a standard individual market health statement to simplify the | 2 |
| health insurance application process for individuals. The | 3 |
| committee shall study health statements currently used by major | 4 |
| carriers in this State who offer individual health insurance | 5 |
| coverage and consolidate the statements into a standard | 6 |
| individual market health statement. The standard individual | 7 |
| market health statement shall be designed to permit its use | 8 |
| both as a written document and through electronic or other | 9 |
| alternative delivery formats. For purposes of the individual | 10 |
| market health statement, the Director may, but shall not be | 11 |
| required to, establish a committee distinct from that formed to | 12 |
| develop an application for small employers. In that event, the | 13 |
| composition of the committee shall be as prescribed in | 14 |
| subsection (b) of this Section, although individual | 15 |
| participants may change. | 16 |
| (h) Beginning January 1, 2011, all carriers who offer | 17 |
| individual health insurance coverage and evaluate the health | 18 |
| status of individuals shall use the standard individual market | 19 |
| health statement. | 20 |
| (i) The Director, as needed, may reconvene the committee to | 21 |
| consider whether changes are necessary to the standard | 22 |
| individual market health statement. If the committee | 23 |
| determines that changes to the statement are necessary, the | 24 |
| Director may adopt revisions to the statement as recommended by | 25 |
| the committee. All carriers who offer individual health | 26 |
| insurance coverage shall use the revised statement beginning 90 |
|
|
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| 1 |
| days after the Director adopts any revision. | 2 |
| (j) Nothing in this Section shall prevent a carrier from | 3 |
| using health information after enrollment for the purpose of | 4 |
| providing services or arranging for the provision of services
| 5 |
| under a health benefit plan or a policy of individual health | 6 |
| insurance coverage. | 7 |
| (k) Nothing in this Section shall be construed to limit or | 8 |
| restrict a health carrier's ability to appropriately rate risk, | 9 |
| refuse to issue or renew coverage, or otherwise rescind, | 10 |
| terminate, or restrict coverage under a health benefit plan or | 11 |
| a policy of individual health insurance coverage or conduct | 12 |
| further review of the information submitted on the statement by | 13 |
| contacting an individual, the individual's health care | 14 |
| provider, or any other entity for additional health status | 15 |
| related information. | 16 |
| (l) Committee members are not eligible for compensation but | 17 |
| may receive reimbursement of expenses. | 18 |
| (215 ILCS 5/359c new)
| 19 |
| Sec. 359c. Accident and health expense reporting. | 20 |
| (a) Beginning January 1, 2011 and every 6 months | 21 |
| thereafter, any carrier providing a group or individual major | 22 |
| medical policy of accident or health insurance shall prepare | 23 |
| and provide to the Department of Insurance a statement of the | 24 |
| aggregate administrative expenses of the carrier, based on the | 25 |
| premiums earned in the immediately preceding 6-month period on |
|
|
|
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| the accident or health insurance business of the carrier. The | 2 |
| semi-annual statements shall be filed on or before July 31 for | 3 |
| the preceding 6-month period ending June 30 and on or before | 4 |
| February 1 for the preceding 6-month period ending December 31. | 5 |
| The statements shall itemize and separately detail all of the | 6 |
| following information with respect to the carrier's accident or | 7 |
| health insurance business: | 8 |
| (1) the amount of premiums earned by the carrier both | 9 |
| before and after any costs related to the carrier's | 10 |
| purchase of reinsurance coverage; | 11 |
| (2) the total amount of claims for losses paid by the | 12 |
| carrier both before and after any reimbursement from | 13 |
| reinsurance coverage including any costs incurred related | 14 |
| to: | 15 |
| (A) disease, case, or chronic care management | 16 |
| programs; | 17 |
| (B) wellness and health education programs; | 18 |
| (C) fraud prevention; | 19 |
| (D) maintaining provider networks and provider | 20 |
| credentialing; | 21 |
| (E) health information technology for personal | 22 |
| electronic health records; and | 23 |
| (F) utilization review and utilization management; | 24 |
| (3) the amount of any losses incurred by the carrier | 25 |
| but not reported to the carrier in the current or prior | 26 |
| reporting period; |
|
|
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| (4) the amount of costs incurred by the carrier for | 2 |
| State fees and federal and State taxes including: | 3 |
| (A) any high risk pool and guaranty fund | 4 |
| assessments levied on the carrier by the State; and | 5 |
| (B) any regulatory compliance costs including | 6 |
| State fees for form and rate filings, licensures, | 7 |
| market conduct exams, and financial reports; | 8 |
| (5) the amount of costs incurred by the carrier for | 9 |
| reinsurance coverage; | 10 |
| (6) the amount of costs incurred by the carrier that | 11 |
| are related to the carrier's payment of marketing expenses | 12 |
| including commissions; and | 13 |
| (7) any other administrative expenses incurred by the | 14 |
| carrier. | 15 |
| (b) The information provided pursuant to subsection (a) of | 16 |
| this Section shall be separately aggregated for the following | 17 |
| lines of major medical insurance: | 18 |
| (1) individually underwritten; | 19 |
| (2) groups of 2 to 25 members; | 20 |
| (3) groups of 26 to 50 members; | 21 |
| (4) groups of 51 or more members. | 22 |
| (c) The Department shall make the submitted information | 23 |
| publicly available on the Department's website or such other | 24 |
| media as appropriate in a form useful for consumers.
| 25 |
| Section 95. The Managed Care Reform and Patient Rights Act |
|
|
|
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| 1 |
| is amended by changing Sections 40 and 45 as follows:
| 2 |
| (215 ILCS 134/40)
| 3 |
| Sec. 40. Access to specialists.
| 4 |
| (a) All health care plans that require each enrollee to | 5 |
| select a
health care provider for any purpose including | 6 |
| coordination of
care shall
permit an enrollee to choose any | 7 |
| available primary care physician licensed to
practice
medicine | 8 |
| in all its branches participating in
the health care plan for | 9 |
| that purpose.
The health care plan shall provide the enrollee | 10 |
| with a choice of licensed
health care providers who are | 11 |
| accessible and
qualified. Nothing in
this Act shall be | 12 |
| construed to prohibit a health care plan from requiring a
| 13 |
| health care provider to meet the health care plan's criteria in | 14 |
| order to
coordinate access to health care.
| 15 |
| (b) A health care plan shall establish a procedure by which | 16 |
| an enrollee who
has a condition that requires ongoing care from | 17 |
| a specialist physician
or other health care provider may apply | 18 |
| for a
standing referral to a specialist physician or other | 19 |
| health care provider if a
referral to a specialist
physician or | 20 |
| other health care provider is required for
coverage.
The | 21 |
| application shall be made to the enrollee's primary care | 22 |
| physician.
This procedure for a standing referral must specify
| 23 |
| the necessary criteria and conditions that must be met in order | 24 |
| for an enrollee
to obtain a standing referral.
A standing | 25 |
| referral shall be effective for the period
necessary to provide |
|
|
|
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| 1 |
| the referred services or one year, except in the event of
| 2 |
| termination of a contract or policy in which case Section 25 on | 3 |
| transition of
services shall apply, if applicable.
A primary | 4 |
| care physician may renew and re-renew a standing referral.
| 5 |
| (c) The enrollee may be required by the health care plan to | 6 |
| select a
specialist physician or other health care provider who | 7 |
| has a referral
arrangement with the enrollee's
primary care | 8 |
| physician or to select a new primary care physician who has a
| 9 |
| referral arrangement with the specialist physician or other | 10 |
| health care
provider chosen by the enrollee.
If a health care | 11 |
| plan requires an enrollee to select a new physician under
this | 12 |
| subsection, the health care plan must provide the enrollee with
| 13 |
| both
options provided in this subsection.
When a participating | 14 |
| specialist with a referral arrangement is not available,
the | 15 |
| primary care physician, in consultation with the enrollee, | 16 |
| shall arrange
for the enrollee to have access to a qualified | 17 |
| participating health care
provider, and the enrollee shall be | 18 |
| allowed to stay with his or her primary
care physician.
If a | 19 |
| secondary referral is necessary, the specialist physician or | 20 |
| other health
care provider shall advise the primary care | 21 |
| physician. The primary care
physician shall be responsible for | 22 |
| making the secondary referral. In addition,
the health care | 23 |
| plan shall require the specialist physician or other health
| 24 |
| care
provider to provide regular updates to the enrollee's | 25 |
| primary care physician.
| 26 |
| (d) When the type of specialist physician or other health |
|
|
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| care provider
needed to provide ongoing care
for a
specific | 2 |
| condition is not represented in the health care plan's provider
| 3 |
| network, the primary care physician shall arrange for the | 4 |
| enrollee to have
access to
a qualified non-participating health | 5 |
| care provider
within a reasonable distance and travel
time at | 6 |
| no additional cost beyond what the enrollee would otherwise pay | 7 |
| for
services received within the network. The referring | 8 |
| physician
shall notify the plan when a referral is made outside | 9 |
| the network.
| 10 |
| (e) The enrollee's primary care physician shall remain | 11 |
| responsible for
coordinating the care of an enrollee who has | 12 |
| received a standing referral to a
specialist physician or other | 13 |
| health care provider.
If a secondary referral is necessary, the | 14 |
| specialist physician or other health
care provider shall advise
| 15 |
| the primary care physician. The primary care physician shall be | 16 |
| responsible
for making the secondary referral.
In addition,
the | 17 |
| health care plan shall require the specialist physician or | 18 |
| other health
care
provider to provide
regular updates to the | 19 |
| enrollee's primary care physician.
| 20 |
| (f) If an enrollee's application for any referral is | 21 |
| denied, an
enrollee may appeal the decision through the
health | 22 |
| care plan's external independent review process as provided by | 23 |
| the Illinois Health Carrier External Review Act in accordance | 24 |
| with
subsection (f) of Section 45 of this Act .
| 25 |
| (g) Nothing in this Act shall be construed to require an | 26 |
| enrollee to select
a new primary care physician when no |
|
|
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| 1 |
| referral arrangement exists between the
enrollee's primary | 2 |
| care physician and the specialist selected by the enrollee
and | 3 |
| when the enrollee has a long-standing relationship with his or | 4 |
| her primary
care physician.
| 5 |
| (h) In promulgating rules to implement this Act, the | 6 |
| Department shall
define
"standing referral" and "ongoing | 7 |
| course of treatment".
| 8 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 9 |
| (215 ILCS 134/45)
| 10 |
| Sec. 45.
Health care services appeals,
complaints, and
| 11 |
| external independent reviews.
| 12 |
| (a) A health care plan shall establish and maintain an | 13 |
| appeals procedure as
outlined in this Act. Compliance with this | 14 |
| Act's appeals procedures shall
satisfy a health care plan's | 15 |
| obligation to provide appeal procedures under any
other State | 16 |
| law or rules.
All appeals of a health care plan's | 17 |
| administrative determinations and
complaints regarding its | 18 |
| administrative decisions shall be handled as required
under | 19 |
| Section 50.
| 20 |
| (b) When an appeal concerns a decision or action by a | 21 |
| health care plan,
its
employees, or its subcontractors that | 22 |
| relates to (i) health care services,
including, but not limited | 23 |
| to, procedures or
treatments,
for an enrollee with an ongoing | 24 |
| course of treatment ordered
by a health care provider,
the | 25 |
| denial of which could significantly
increase the risk to an
|
|
|
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| 1 |
| enrollee's health,
or (ii) a treatment referral, service,
| 2 |
| procedure, or other health care service,
the denial of which | 3 |
| could significantly
increase the risk to an
enrollee's health,
| 4 |
| the health care plan must allow for the filing of an appeal
| 5 |
| either orally or in writing. Upon submission of the appeal, a | 6 |
| health care plan
must notify the party filing the appeal, as | 7 |
| soon as possible, but in no event
more than 24 hours after the | 8 |
| submission of the appeal, of all information
that the plan | 9 |
| requires to evaluate the appeal.
The health care plan shall | 10 |
| render a decision on the appeal within
24 hours after receipt | 11 |
| of the required information. The health care plan shall
notify | 12 |
| the party filing the
appeal and the enrollee, enrollee's | 13 |
| primary care physician, and any health care
provider who | 14 |
| recommended the health care service involved in the appeal of | 15 |
| its
decision orally
followed-up by a written notice of the | 16 |
| determination.
| 17 |
| (c) For all appeals related to health care services | 18 |
| including, but not
limited to, procedures or treatments for an | 19 |
| enrollee and not covered by
subsection (b) above, the health | 20 |
| care
plan shall establish a procedure for the filing of such | 21 |
| appeals. Upon
submission of an appeal under this subsection, a | 22 |
| health care plan must notify
the party filing an appeal, within | 23 |
| 3 business days, of all information that the
plan requires to | 24 |
| evaluate the appeal.
The health care plan shall render a | 25 |
| decision on the appeal within 15 business
days after receipt of | 26 |
| the required information. The health care plan shall
notify the |
|
|
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| 1 |
| party filing the appeal,
the enrollee, the enrollee's primary | 2 |
| care physician, and any health care
provider
who recommended | 3 |
| the health care service involved in the appeal orally of its
| 4 |
| decision followed-up by a written notice of the determination.
| 5 |
| (d) An appeal under subsection (b) or (c) may be filed by | 6 |
| the
enrollee, the enrollee's designee or guardian, the | 7 |
| enrollee's primary care
physician, or the enrollee's health | 8 |
| care provider. A health care plan shall
designate a clinical | 9 |
| peer to review
appeals, because these appeals pertain to | 10 |
| medical or clinical matters
and such an appeal must be reviewed | 11 |
| by an appropriate
health care professional. No one reviewing an | 12 |
| appeal may have had any
involvement
in the initial | 13 |
| determination that is the subject of the appeal. The written
| 14 |
| notice of determination required under subsections (b) and (c) | 15 |
| shall
include (i) clear and detailed reasons for the | 16 |
| determination, (ii)
the medical or
clinical criteria for the | 17 |
| determination, which shall be based upon sound
clinical | 18 |
| evidence and reviewed on a periodic basis, and (iii) in the | 19 |
| case of an
adverse determination, the
procedures for requesting | 20 |
| an external independent review as provided by the Illinois | 21 |
| Health Carrier External Review Act under subsection (f) .
| 22 |
| (e) If an appeal filed under subsection (b) or (c) is | 23 |
| denied for a reason
including, but not limited to, the
service, | 24 |
| procedure, or treatment is not viewed as medically necessary,
| 25 |
| denial of specific tests or procedures, denial of referral
to | 26 |
| specialist physicians or denial of hospitalization requests or |
|
|
|
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| 1 |
| length of
stay requests, any involved party may request an | 2 |
| external independent review as provided by the Illinois Health | 3 |
| Carrier External Review Act
under subsection (f) of the adverse | 4 |
| determination .
| 5 |
| (f) Until July 1, 2013, if an external independent review | 6 |
| decision made pursuant to the Illinois Health Carrier External | 7 |
| Review Act upholds a determination adverse to the covered | 8 |
| person, the covered person has the right to appeal the final | 9 |
| decision to the Department; if the external review decision is | 10 |
| found by the Director to have been arbitrary and capricious, | 11 |
| then the Director, with consultation from a licensed medical | 12 |
| professional, may overturn the external review decision and | 13 |
| require the health carrier to pay for the health care service | 14 |
| or treatment; such decision, if any, shall be made solely on | 15 |
| the legal or medical merits of the claim. External independent | 16 |
| review.
| 17 |
| (1) The party seeking an external independent review | 18 |
| shall so notify the
health care plan.
The health care plan | 19 |
| shall seek to resolve all
external independent
reviews in | 20 |
| the most expeditious manner and shall make a determination | 21 |
| and
provide notice of the determination no more
than 24 | 22 |
| hours after the receipt of all necessary information when a | 23 |
| delay would
significantly increase
the risk to an | 24 |
| enrollee's health or when extended health care services for | 25 |
| an
enrollee undergoing a
course of treatment prescribed by | 26 |
| a health care provider are at issue.
|
|
|
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| 1 |
| (2) Within 30 days after the enrollee receives written | 2 |
| notice of an
adverse
determination,
if the enrollee decides | 3 |
| to initiate an external independent review, the
enrollee | 4 |
| shall send to the health
care plan a written request for an | 5 |
| external independent review, including any
information or
| 6 |
| documentation to support the enrollee's request for the | 7 |
| covered service or
claim for a covered
service.
| 8 |
| (3) Within 30 days after the health care plan receives | 9 |
| a request for an
external
independent review from an | 10 |
| enrollee, the health care plan shall:
| 11 |
| (A) provide a mechanism for joint selection of an | 12 |
| external independent
reviewer by the enrollee, the | 13 |
| enrollee's physician or other health care
provider,
| 14 |
| and the health care plan; and
| 15 |
| (B) forward to the independent reviewer all | 16 |
| medical records and
supporting
documentation | 17 |
| pertaining to the case, a summary description of the | 18 |
| applicable
issues including a
statement of the health | 19 |
| care plan's decision, the criteria used, and the
| 20 |
| medical and clinical reasons
for that decision.
| 21 |
| (4) Within 5 days after receipt of all necessary | 22 |
| information, the
independent
reviewer
shall evaluate and | 23 |
| analyze the case and render a decision that is based on
| 24 |
| whether or not the health
care service or claim for the | 25 |
| health care service is medically appropriate. The
decision | 26 |
| by the
independent reviewer is final. If the external |
|
|
|
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LRB096 08394 RPM 27471 a |
|
| 1 |
| independent reviewer determines
the health care
service to | 2 |
| be medically
appropriate, the health
care plan shall pay | 3 |
| for the health care service.
| 4 |
| (5) The health care plan shall be solely responsible | 5 |
| for paying the fees
of the external
independent reviewer | 6 |
| who is selected to perform the review.
| 7 |
| (6) An external independent reviewer who acts in good | 8 |
| faith shall have
immunity
from any civil or criminal | 9 |
| liability or professional discipline as a result of
acts or | 10 |
| omissions with
respect to any external independent review, | 11 |
| unless the acts or omissions
constitute wilful and wanton
| 12 |
| misconduct. For purposes of any proceeding, the good faith | 13 |
| of the person
participating shall be
presumed.
| 14 |
| (7) Future contractual or employment action by the | 15 |
| health care plan
regarding the
patient's physician or other | 16 |
| health care provider shall not be based solely on
the | 17 |
| physician's or other
health care provider's participation | 18 |
| in this procedure.
| 19 |
| (8) For the purposes of this Section, an external | 20 |
| independent reviewer
shall:
| 21 |
| (A) be a clinical peer;
| 22 |
| (B) have no direct financial interest in | 23 |
| connection with the case; and
| 24 |
| (C) have not been informed of the specific identity | 25 |
| of the enrollee.
| 26 |
| (g) Nothing in this Section shall be construed to require a |
|
|
|
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|
| 1 |
| health care
plan to pay for a health care service not covered | 2 |
| under the enrollee's
certificate of coverage or policy.
| 3 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 4 |
| Section 96. No acceleration or delay. Where this Act makes | 5 |
| changes in a statute that is represented in this Act by text | 6 |
| that is not yet or no longer in effect (for example, a Section | 7 |
| represented by multiple versions), the use of that text does | 8 |
| not accelerate or delay the taking effect of (i) the changes | 9 |
| made by this Act or (ii) provisions derived from any other | 10 |
| Public Act. | 11 |
| Section 97. Severability. The provisions of this Act are | 12 |
| severable under Section 1.31 of the Statute on Statutes. | 13 |
| Section 99. Effective date. This Act takes effect January | 14 |
| 1, 2010, except that the changes to Section 155.36 of the | 15 |
| Illinois Insurance Code and Sections 40 and 45 of the Managed | 16 |
| Care Reform and Patient Rights Act and the Health Carrier | 17 |
| External Review Act take effect July 1, 2010.".
|
|