Full Text of SB1506 96th General Assembly
SB1506sam002 96TH GENERAL ASSEMBLY
|
Sen. Jacqueline Y. Collins
Filed: 3/25/2009
|
|
09600SB1506sam002 |
|
LRB096 10769 RPM 24366 a |
|
| 1 |
| AMENDMENT TO SENATE BILL 1506
| 2 |
| AMENDMENT NO. ______. Amend Senate Bill 1506, AS AMENDED, | 3 |
| by replacing everything after the enacting clause with the | 4 |
| following:
| 5 |
| "Section 1. Short title. This Act may be cited as the | 6 |
| Health Carrier External Review Act. | 7 |
| Section 5. Purpose and intent. The purpose of this Act is | 8 |
| to provide uniform standards for the establishment and | 9 |
| maintenance of external review procedures to assure that | 10 |
| covered persons have the opportunity for an independent review | 11 |
| of an adverse determination or final adverse determination, as | 12 |
| defined in this Act. | 13 |
| Section 10. Definitions. For the purposes of this Act: | 14 |
| "Adverse determination" means a determination by a health | 15 |
| carrier or its designee utilization review organization that an |
|
|
|
09600SB1506sam002 |
- 2 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| admission, availability of care, continued stay, or other | 2 |
| health care service that is a covered benefit has been reviewed | 3 |
| and, based upon the information provided, does not meet the | 4 |
| health carrier's requirements for medical necessity, | 5 |
| appropriateness, health care setting, level of care, or | 6 |
| effectiveness, and the requested service or payment for the | 7 |
| service is therefore denied, reduced, or terminated. | 8 |
| "Authorized representative" means: | 9 |
| (1) a person to whom a covered person has given express | 10 |
| written consent to represent the covered person in an | 11 |
| external review; | 12 |
| (2) a person authorized by law to provide substituted | 13 |
| consent for a covered person; or | 14 |
| (3) a family member of the covered person or the | 15 |
| covered person's health care provider only when the covered | 16 |
| person is unable to provide consent. | 17 |
| "Best evidence " means evidence based on: | 18 |
| (1) randomized clinical trials; | 19 |
| (2) if randomized clinical trials are not available, | 20 |
| then cohort studies or case-control studies; | 21 |
| (3) if items (1) and (2) are not available, then | 22 |
| case-series; or | 23 |
| (4) if items (1), (2), and (3) are not available, then | 24 |
| expert opinion. | 25 |
| "Case-series " means an evaluation of a series of patients | 26 |
| with a particular outcome, without the use of a control group. |
|
|
|
09600SB1506sam002 |
- 3 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| "Clinical review criteria" means the written screening | 2 |
| procedures, decision abstracts, clinical protocols, and | 3 |
| practice guidelines used by a health carrier to determine the | 4 |
| necessity and appropriateness of health care services. | 5 |
| "Cohort study" means a prospective evaluation of 2 groups | 6 |
| of patients with only one group of patients receiving specific | 7 |
| intervention. | 8 |
| "Covered benefits" or "benefits" means those health care | 9 |
| services to which a covered person is entitled under the terms | 10 |
| of a health benefit plan. | 11 |
| "Covered person" means a policyholder, subscriber, | 12 |
| enrollee, or other individual participating in a health benefit | 13 |
| plan. | 14 |
| "Director" means the Director of the Division of Insurance | 15 |
| within the Illinois Department of Financial and Professional | 16 |
| Regulation. | 17 |
| "Emergency medical condition" means the sudden onset of a | 18 |
| health condition or illness that requires immediate medical | 19 |
| attention, where failure to provide medical attention would | 20 |
| result in a serious impairment to bodily functions, serious | 21 |
| dysfunction of a bodily organ or part, or would place the | 22 |
| person's health in serious jeopardy. | 23 |
| "Emergency services" means health care items and services | 24 |
| furnished or required to evaluate and treat an emergency | 25 |
| medical condition. | 26 |
| "Evidence-based standard" means the conscientious, |
|
|
|
09600SB1506sam002 |
- 4 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| explicit, and judicious use of the current best evidence based | 2 |
| on an overall systematic review of the research in making | 3 |
| decisions about the care of individual patients. | 4 |
| "Expert opinion" means a belief or an interpretation by | 5 |
| specialists with experience in a specific area about the | 6 |
| scientific evidence pertaining to a particular service, | 7 |
| intervention, or therapy. | 8 |
| "Facility" means an institution providing health care | 9 |
| services or a health care setting. | 10 |
| "Final adverse determination" means an adverse | 11 |
| determination involving a covered benefit that has been upheld | 12 |
| by a health carrier, or its designee utilization review | 13 |
| organization, at the completion of the health carrier's | 14 |
| internal grievance process procedures as set forth by the | 15 |
| American Accreditation Health Care Commission. | 16 |
| "Health benefit plan" means a policy, contract, | 17 |
| certificate, plan, or agreement offered or issued by a health | 18 |
| carrier to provide, deliver, arrange for, pay for, or reimburse | 19 |
| any of the costs of health care services. | 20 |
| "Health care provider" or "provider" means a physician or | 21 |
| other health care practitioner licensed, accredited, or | 22 |
| certified to perform specified health care services consistent | 23 |
| with State law, responsible for recommending health care | 24 |
| services on behalf of a covered person. | 25 |
| "Health care services" means services for the diagnosis, | 26 |
| prevention, treatment, cure, or relief of a health condition, |
|
|
|
09600SB1506sam002 |
- 5 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| illness, injury, or disease. | 2 |
| "Health carrier" means an entity subject to the insurance | 3 |
| laws and regulations of this State, or subject to the | 4 |
| jurisdiction of the Director, that contracts or offers to | 5 |
| contract to provide, deliver, arrange for, pay for, or | 6 |
| reimburse any of the costs of health care services, including a | 7 |
| sickness and accident insurance company, a health maintenance | 8 |
| organization, a nonprofit hospital and health service | 9 |
| corporation, or any other entity providing a plan of health | 10 |
| insurance, health benefits, or health care services. "Health | 11 |
| carrier" also means Limited Health Service Organizations | 12 |
| (LHSO) and Voluntary Health Service Plans. | 13 |
| "Health carrier" does not include a managed care plan as | 14 |
| defined in the Managed Care Reform and Patient Rights Act. | 15 |
| "Health information" means information or data, whether | 16 |
| oral or recorded in any form or medium, and personal facts or | 17 |
| information about events or relationships that relate to:
| 18 |
| (1) the past, present, or future physical, mental, or | 19 |
| behavioral health or condition of an individual or a member | 20 |
| of the individual's family; | 21 |
| (2) the provision of health care services to an | 22 |
| individual; or | 23 |
| (3) payment for the provision of health care services | 24 |
| to an individual. | 25 |
| "Independent review organization" means an entity that | 26 |
| conducts independent external reviews of adverse |
|
|
|
09600SB1506sam002 |
- 6 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| determinations and final adverse determinations. | 2 |
| "Medical or scientific evidence" means evidence found in | 3 |
| the following sources: | 4 |
| (1) peer-reviewed scientific studies published in or | 5 |
| accepted for publication by medical journals that meet | 6 |
| nationally recognized requirements for scientific | 7 |
| manuscripts and that submit most of their published | 8 |
| articles for review by experts who are not part of the | 9 |
| editorial staff; | 10 |
| (2) peer-reviewed medical literature, including | 11 |
| literature relating to therapies reviewed and approved by a | 12 |
| qualified institutional review board, biomedical | 13 |
| compendia, and other medical literature that meet the | 14 |
| criteria of the National Institutes of Health's Library of | 15 |
| Medicine for indexing in Index Medicus (Medline) and | 16 |
| Elsevier Science Ltd. for indexing in Excerpta Medicus | 17 |
| (EMBASE); | 18 |
| (3) medical journals recognized by the Secretary of | 19 |
| Health and Human Services under Section 1861(t)(2) of the | 20 |
| federal Social Security Act; | 21 |
| (4) the following standard reference compendia:
| 22 |
| (a) The American Hospital Formulary Service-Drug | 23 |
| Information; | 24 |
| (b) Drug Facts and Comparisons; | 25 |
| (c) The American Dental Association Accepted | 26 |
| Dental Therapeutics; and |
|
|
|
09600SB1506sam002 |
- 7 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| (d) The United States Pharmacopoeia-Drug | 2 |
| Information; | 3 |
| (5) findings, studies, or research conducted by or | 4 |
| under the auspices of federal government agencies and | 5 |
| nationally recognized federal research institutes, | 6 |
| including: | 7 |
| (a) the federal Agency for Healthcare Research and | 8 |
| Quality; | 9 |
| (b) the National Institutes of Health; | 10 |
| (c) the National Cancer Institute; | 11 |
| (d) the National Academy of Sciences; | 12 |
| (e) the Centers for Medicare & Medicaid Services; | 13 |
| (f) the federal Food and Drug Administration; and | 14 |
| (g) any national board recognized by the National | 15 |
| Institutes of Health for the purpose of evaluating the | 16 |
| medical value of health care services; or | 17 |
| (6) any other medical or scientific evidence that is | 18 |
| comparable to the sources listed in items (1) through (5). | 19 |
| "Protected health information" means health information | 20 |
| (i) that identifies an individual who is the subject of the | 21 |
| information; or (ii) with respect to which there is a | 22 |
| reasonable basis to believe that the information could be used | 23 |
| to identify an individual. | 24 |
| "Retrospective review" means a review of medical necessity | 25 |
| conducted after services have been provided to a patient, but | 26 |
| does not include the review of a claim that is limited to an |
|
|
|
09600SB1506sam002 |
- 8 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| evaluation of reimbursement levels, veracity of documentation, | 2 |
| accuracy of coding, or adjudication for payment. | 3 |
| "Utilization review" has the meaning provided by the | 4 |
| American Accreditation Health Care Commission. | 5 |
| "Utilization review organization" means a utilization | 6 |
| review program as defined by the American Accreditation Health | 7 |
| Care Commission. | 8 |
| Section 15. Applicability and scope. | 9 |
| (a) Except as provided in subsection (b) of this Section, | 10 |
| this Act shall apply to all health carriers. | 11 |
| (b) The provisions of this Act shall not apply to a policy | 12 |
| or certificate that provides coverage only for a specified | 13 |
| disease, specified accident or accident-only coverage, credit, | 14 |
| dental, disability income, hospital indemnity, long-term care | 15 |
| insurance as defined by Article XIXA of the Illinois Insurance | 16 |
| Code, vision care, or any other limited supplemental benefit; a | 17 |
| Medicare supplement policy of insurance as defined by the | 18 |
| Director by regulation; coverage under a plan through Medicare, | 19 |
| Medicaid, or the federal employees health benefits program; any | 20 |
| coverage issued under Chapter 55 of Title 10, U.S. Code and any | 21 |
| coverage issued as supplement to that coverage; any coverage | 22 |
| issued as supplemental to liability insurance, workers' | 23 |
| compensation, or similar insurance; automobile medical-payment | 24 |
| insurance or any insurance under which benefits are payable | 25 |
| with or without regard to fault, whether written on a group |
|
|
|
09600SB1506sam002 |
- 9 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| blanket or individual basis; or any managed care plan as | 2 |
| defined in the Managed Care Reform and Patient Rights Act.
| 3 |
| Section 20. Notice of right to external review. | 4 |
| (a) At the same time the health carrier sends written | 5 |
| notice of an adverse determination upon completion of the | 6 |
| health carrier's utilization review process as provided by the | 7 |
| American Accreditation Health Care Commission and a final | 8 |
| adverse determination, 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. | 12 |
| (1) The written notice required shall include the | 13 |
| following, or substantially equivalent, language: "We have | 14 |
| denied your request for the provision of or payment for a | 15 |
| health care service or course of treatment. You have the | 16 |
| right to have our decision reviewed by an independent | 17 |
| review organization not associated with us if our decision | 18 |
| involved making a judgment as to the medical necessity, | 19 |
| appropriateness, health care setting, level of care, or | 20 |
| effectiveness of the health care service or treatment you | 21 |
| requested by submitting a written request for an external | 22 |
| review to us. Upon receipt of your request an independent | 23 |
| review organization registered with the Department of | 24 |
| Financial and Professional Regulation, Division of | 25 |
| Insurance will be assigned to review our decision.". |
|
|
|
09600SB1506sam002 |
- 10 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| (2) The notice shall also include the appropriate | 2 |
| statements and information set forth in subsections (b) and | 3 |
| (c) of this Section. | 4 |
| (b) The health carrier shall include in the notice required | 5 |
| under subsection (a) of this Section for a notice related to an | 6 |
| adverse determination, a statement informing the covered | 7 |
| person that: | 8 |
| (1) if the covered person has a medical condition where | 9 |
| the timeframe for completion of an expedited internal | 10 |
| review of a grievance involving an adverse determination | 11 |
| would seriously jeopardize the life or health of the | 12 |
| covered person or would jeopardize the covered person's | 13 |
| ability to regain maximum function or if the adverse | 14 |
| determination involves a denial of coverage based on a | 15 |
| determination that the recommended or requested health | 16 |
| care service or treatment is experimental or | 17 |
| investigational and the covered person's treating | 18 |
| physician certifies in writing that the recommended or | 19 |
| requested health care service or treatment that is the | 20 |
| subject of the adverse determination would be | 21 |
| significantly less effective if not promptly initiated, | 22 |
| then the covered person or the covered person's authorized | 23 |
| representative may file a request for an expedited external | 24 |
| review at the same time the covered person or the covered | 25 |
| person's authorized representative files a request for an | 26 |
| expedited internal appeal involving an adverse |
|
|
|
09600SB1506sam002 |
- 11 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| determination as set forth by the American Accreditation | 2 |
| Health Care Commission. The independent review | 3 |
| organization assigned to conduct the expedited external | 4 |
| review will determine whether the covered person shall be | 5 |
| required to complete the expedited review of the grievance | 6 |
| prior to conducting the expedited external review; and | 7 |
| (2) the covered person or the covered person's | 8 |
| authorized representative may file a grievance under the | 9 |
| health carrier's internal grievance process as set forth by | 10 |
| the American Accreditation Health Care Commission, but if | 11 |
| the health carrier has not issued a written decision to the | 12 |
| covered person or the covered person's authorized | 13 |
| representative within 30 days following the date the | 14 |
| covered person or the covered person's authorized | 15 |
| representative files the grievance with the health carrier | 16 |
| and the covered person or the covered person's authorized | 17 |
| representative has not requested or agreed to a delay, then | 18 |
| the covered person or the covered person's authorized | 19 |
| representative may file a request for external review and | 20 |
| shall be considered to have exhausted the health carrier's | 21 |
| internal grievance process. | 22 |
| (c) The health carrier shall include in the notice required | 23 |
| under subsection (a) of this Section for a notice related to a | 24 |
| final adverse determination, a statement informing the covered | 25 |
| person that: | 26 |
| (1) if the covered person has a medical condition where |
|
|
|
09600SB1506sam002 |
- 12 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| the timeframe for completion of a standard external review | 2 |
| would seriously jeopardize the life or health of the | 3 |
| covered person or would jeopardize the covered person's | 4 |
| ability to regain maximum function, then the covered person | 5 |
| or the covered person's authorized representative may file | 6 |
| a request for an expedited external review; or | 7 |
| (2) if a final adverse determination concerns: | 8 |
| (i) an admission, availability of care, continued | 9 |
| stay, or health care service for which the covered | 10 |
| person received emergency services, but has not been | 11 |
| discharged from a facility, then the covered person, or | 12 |
| the covered person's authorized representative, may | 13 |
| request an expedited external review; or | 14 |
| (ii) a denial of coverage based on a determination | 15 |
| that the recommended or requested health care service | 16 |
| or treatment is experimental or investigational, and | 17 |
| the covered person's health care provider certifies in | 18 |
| writing that the recommended or requested health care | 19 |
| service or treatment that is the subject of the request | 20 |
| would be significantly less effective if not promptly | 21 |
| initiated, then the covered person or the covered | 22 |
| person's authorized representative may request an | 23 |
| expedited external review.
| 24 |
| (d) In addition to the information to be provided pursuant | 25 |
| to subsections (a), (b), and (c) of this Section, the health | 26 |
| carrier shall include a copy of the description of both the |
|
|
|
09600SB1506sam002 |
- 13 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| required standard and expedited external review procedures. | 2 |
| The description shall highlight the external review procedures | 3 |
| that give the covered person or the covered person's authorized | 4 |
| representative the opportunity to submit additional | 5 |
| information, including any forms used to process an external | 6 |
| review. | 7 |
| Section 25. Request for external review. A covered person | 8 |
| or the covered person's authorized representative may make a | 9 |
| request for a standard external or expedited external review of | 10 |
| an adverse determination or final adverse determination. | 11 |
| Requests under this Section shall be made directly to the | 12 |
| health carrier that made the adverse or final adverse | 13 |
| determination. All requests for external review shall be in | 14 |
| writing except for requests for expedited external reviews | 15 |
| which may me made orally. Health carriers must provide covered | 16 |
| persons with forms to request external reviews. | 17 |
| Section 30. Exhaustion of internal grievance process. | 18 |
| (a) Except as provided in item (1) of subsection (b) of | 19 |
| Section 20 of this Act, a request for an external review shall | 20 |
| not be made until the covered person has exhausted the health | 21 |
| carrier's internal grievance process as set forth by the | 22 |
| American Accreditation Health Care Commission. | 23 |
| (b) A covered person shall be considered to have exhausted | 24 |
| the health carrier's internal grievance process for purposes of |
|
|
|
09600SB1506sam002 |
- 14 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| this Section if the covered person or the covered person's | 2 |
| authorized representative filed a request for an internal | 3 |
| review of an adverse determination pursuant to the American | 4 |
| Accreditation Health Care Commission and has not received a | 5 |
| written decision on the request from the health carrier within | 6 |
| 30 days after the request is filed, except to the extent the | 7 |
| covered person or the covered person's authorized | 8 |
| representative requested or agreed to a delay. | 9 |
| (c) Notwithstanding subsection (b) of this Section, a | 10 |
| covered person or the covered person's authorized | 11 |
| representative may not make a request for an external review of | 12 |
| an adverse determination involving a retrospective review | 13 |
| determination until the covered person has exhausted the health | 14 |
| carrier's internal grievance process. | 15 |
| (d) Upon request for an expedited external review pursuant | 16 |
| to item (1) of subsection (b) of Section 20 of this Act, the | 17 |
| independent review organization conducting the external review | 18 |
| shall determine whether the covered person shall be required to | 19 |
| complete the expedited review process set forth by the American | 20 |
| Accreditation Health Care Commission before it conducts the | 21 |
| expedited external review. Upon determination that the covered | 22 |
| person must first complete the expedited grievance review | 23 |
| process, the independent review organization immediately shall | 24 |
| notify the covered person and, if applicable, the covered | 25 |
| person's authorized representative of this determination and | 26 |
| that it will not proceed with the expedited external review |
|
|
|
09600SB1506sam002 |
- 15 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| until completion of the expedited grievance review process and | 2 |
| that covered person's grievance at the completion of the | 3 |
| expedited grievance review process remains unresolved. | 4 |
| (e) A covered person need not exhaust a heath carrier's | 5 |
| internal grievance procedures as set forth by the American | 6 |
| Accreditation Health Care Commission, if the health carrier | 7 |
| agrees to waive the exhaustion requirement. | 8 |
| Section 35. Standard external review. | 9 |
| (a) Within 4 months after the date of receipt of a notice | 10 |
| of an adverse determination or final adverse determination, a | 11 |
| covered person or the covered person's authorized | 12 |
| representative may file a request for an external review with | 13 |
| the health carrier. | 14 |
| (b) Within 5 business days following the date of receipt of | 15 |
| the external review request, the health carrier shall complete | 16 |
| a preliminary review of the request to determine whether:
| 17 |
| (1) the individual is or was a covered person in the | 18 |
| health benefit plan at the time the health care service was | 19 |
| requested or at the time the health care service was | 20 |
| provided; | 21 |
| (2) either of the following situations is applicable: | 22 |
| (A) the health care service that is the subject of | 23 |
| the adverse determination or the final adverse | 24 |
| determination is a covered service under the covered | 25 |
| person's health benefit plan, but the health carrier |
|
|
|
09600SB1506sam002 |
- 16 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| has determined that the health care service is not | 2 |
| covered because it does not meet the health carrier's | 3 |
| requirements for medical necessity, appropriateness, | 4 |
| health care setting, level of care, or effectiveness; | 5 |
| or | 6 |
| (B) the recommended or requested health care | 7 |
| service or treatment that is the subject of the adverse | 8 |
| determination or final adverse determination is a | 9 |
| covered benefit under the covered person's health | 10 |
| benefit plan except for the health carrier's | 11 |
| determination that the service or treatment is | 12 |
| experimental or investigational for a particular | 13 |
| medical condition and is not explicitly listed as an | 14 |
| excluded benefit under the covered person's health | 15 |
| benefit plan with the health carrier; | 16 |
| (3) the covered person's treating physician has | 17 |
| certified that one of the following situations is | 18 |
| applicable: | 19 |
| (A) standard health care services or treatments | 20 |
| have not been effective in improving the condition of | 21 |
| the covered person; | 22 |
| (B) standard health care services or treatments | 23 |
| are not medically appropriate for the covered person; | 24 |
| or | 25 |
| (C) there is no available standard health care | 26 |
| service or treatment covered by the health carrier that |
|
|
|
09600SB1506sam002 |
- 17 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| is more beneficial than the recommended or requested | 2 |
| health care service or treatment described in item (4) | 3 |
| of this subsection (b);
| 4 |
| (4) the covered person's treating physician: | 5 |
| (A) has recommended a health care service or | 6 |
| treatment that the physician certifies, in writing, is | 7 |
| likely to be more beneficial to the covered person, in | 8 |
| the physician's opinion, than any available standard | 9 |
| health care service or treatment; or | 10 |
| (B) who is a licensed, board certified, or board | 11 |
| eligible physician qualified to practice in the area of | 12 |
| medicine appropriate to treat the covered person's | 13 |
| condition, has certified in writing that | 14 |
| scientifically valid studies using accepted protocols | 15 |
| demonstrate that the health care service or treatment | 16 |
| requested by the covered person that is the subject of | 17 |
| the adverse determination or final adverse | 18 |
| determination is likely to be more beneficial to the | 19 |
| covered person than any available standard health care | 20 |
| services or treatments; | 21 |
| (5) the covered person has exhausted the health | 22 |
| carrier's internal grievance process as set forth in | 23 |
| Section 30 of this Act; and | 24 |
| (6) the covered person has provided all the information | 25 |
| and forms required to process an external review as | 26 |
| specified in this Act. |
|
|
|
09600SB1506sam002 |
- 18 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| (c) Within one business day after completion of the | 2 |
| preliminary review, the health carrier shall notify the covered | 3 |
| person and, if applicable, the covered person's authorized | 4 |
| representative in writing whether the request is complete and | 5 |
| eligible for external review. If the request: | 6 |
| (1) is not complete, the health carrier shall inform | 7 |
| the covered person and, if applicable, the covered person's | 8 |
| authorized representative in writing and include in the | 9 |
| notice what information or materials are required by this | 10 |
| Act to make the request complete; or | 11 |
| (2) is not eligible for external review, the health | 12 |
| carrier shall inform the covered person and, if applicable, | 13 |
| the covered person's authorized representative in writing | 14 |
| and include in the notice the reasons for its | 15 |
| ineligibility.
| 16 |
| The notice of initial determination of ineligibility shall | 17 |
| include a statement informing the covered person and, if | 18 |
| applicable, the covered person's authorized representative | 19 |
| that a health carrier's initial determination that the external | 20 |
| review request is ineligible for review may be appealed to the | 21 |
| Director by filing a complaint with the Director. | 22 |
| Notwithstanding a health carrier's initial determination | 23 |
| that the request is ineligible for external review, the | 24 |
| Director may determine that a request is eligible for external | 25 |
| review and require that it be referred for external review. In | 26 |
| making such determination, the Director's decision shall be in |
|
|
|
09600SB1506sam002 |
- 19 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| accordance with the terms of the covered person's health | 2 |
| benefit plan and shall be subject to all applicable provisions | 3 |
| of this Act. | 4 |
| (d) Whenever a request is eligible for external review the | 5 |
| health carrier shall, within 5 business days: | 6 |
| (1) assign an independent review organization from the | 7 |
| list of approved independent review organizations compiled | 8 |
| and maintained by the Director; and | 9 |
| (2) notify in writing the covered person and, if | 10 |
| applicable, the covered person's authorized representative | 11 |
| of the request's eligibility and acceptance for external | 12 |
| review and the name of the independent review organization. | 13 |
| The health carrier shall include in the notice provided to | 14 |
| the covered person and, if applicable, the covered person's | 15 |
| authorized representative a statement that the covered person | 16 |
| or the covered person's authorized representative may, within 5 | 17 |
| business days following the date of receipt of the notice | 18 |
| provided pursuant to item (2) of this subsection (d), submit in | 19 |
| writing to the assigned independent review organization | 20 |
| additional information that the independent review | 21 |
| organization shall consider when conducting the external | 22 |
| review. The independent review organization is not required to, | 23 |
| but may, accept and consider additional information submitted | 24 |
| after 5 business days. | 25 |
| (e) The assignment of an approved independent review | 26 |
| organization to conduct an external review in accordance with |
|
|
|
09600SB1506sam002 |
- 20 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| this Section shall be done on a random basis among those | 2 |
| approved independent review organizations qualified to conduct | 3 |
| external review except for instances of conflict of interest | 4 |
| concerns pursuant to this Act. | 5 |
| (f) Upon assignment of an independent review organization, | 6 |
| the health carrier or its designee utilization review | 7 |
| organization shall, within 5 business days, provide to the | 8 |
| assigned independent review organization the documents and any | 9 |
| information considered in making the adverse determination or | 10 |
| final adverse determination; in such cases, the following | 11 |
| provisions shall apply: | 12 |
| (1) Except as provided in item (2) of this subsection | 13 |
| (f), failure by the health carrier or its utilization | 14 |
| review organization to provide the documents and | 15 |
| information within the specified time frame shall not delay | 16 |
| the conduct of the external review. | 17 |
| (2) If the health carrier or its utilization review | 18 |
| organization fails to provide the documents and | 19 |
| information within the specified time frame, the assigned | 20 |
| independent review organization may terminate the external | 21 |
| review and make a decision to reverse the adverse | 22 |
| determination or final adverse determination. | 23 |
| (3) Within one business day after making the decision | 24 |
| to terminate the external review and make a decision to | 25 |
| reverse the adverse determination or final adverse | 26 |
| determination under item (2) of this subsection (f), the |
|
|
|
09600SB1506sam002 |
- 21 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| independent review organization shall notify the health | 2 |
| carrier, the covered person and, if applicable, the covered | 3 |
| person's authorized representative, of its decision to | 4 |
| reverse the adverse determination. | 5 |
| (g) Upon receipt of the information from the health carrier | 6 |
| or its utilization review organization, the assigned | 7 |
| independent review organization shall review all of the | 8 |
| information and documents and any other information submitted | 9 |
| in writing to the independent review organization by the | 10 |
| covered person and the covered person's authorized | 11 |
| representative. | 12 |
| (h) Upon receipt of any information submitted by the | 13 |
| covered person or the covered person's authorized | 14 |
| representative, the independent review organization shall | 15 |
| forward the information to the health carrier within 1 business | 16 |
| day. | 17 |
| (1) Upon receipt of the information, if any, the health | 18 |
| carrier may reconsider its adverse determination or final | 19 |
| adverse determination that is the subject of the external | 20 |
| review.
| 21 |
| (2) Reconsideration by the health carrier of its | 22 |
| adverse determination or final adverse determination shall | 23 |
| not delay or terminate the external review.
| 24 |
| (3) The external review may only be terminated if the | 25 |
| health carrier decides, upon completion of its | 26 |
| reconsideration, to reverse its adverse determination or |
|
|
|
09600SB1506sam002 |
- 22 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| final adverse determination and provide coverage or | 2 |
| payment for the health care service that is the subject of | 3 |
| the adverse determination or final adverse determination. | 4 |
| In such cases, the following provisions shall apply: | 5 |
| (A) Within one business day after making the | 6 |
| decision to reverse its adverse determination or final | 7 |
| adverse determination, the health carrier shall notify | 8 |
| the covered person, if applicable, the covered | 9 |
| person's authorized representative, and the assigned | 10 |
| independent review organization in writing of its | 11 |
| decision. | 12 |
| (B) Upon notice from the health carrier that the | 13 |
| health carrier has made a decision to reverse its | 14 |
| adverse determination or final adverse determination, | 15 |
| the assigned independent review organization shall | 16 |
| terminate the external review. | 17 |
| (i) In addition to the documents and information provided | 18 |
| by the health carrier or its utilization review organization | 19 |
| and the covered person and the covered person's authorized | 20 |
| representative, if any, the independent review organization, | 21 |
| to the extent the information or documents are available and | 22 |
| the independent review organization considers them | 23 |
| appropriate, shall consider the following in reaching a | 24 |
| decision: | 25 |
| (1) for an adverse determination or final adverse | 26 |
| determination: |
|
|
|
09600SB1506sam002 |
- 23 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| (A) the covered person's pertinent medical | 2 |
| records; | 3 |
| (B) the covered person's health care provider's | 4 |
| recommendation; | 5 |
| (C) consulting reports from appropriate health | 6 |
| care providers and other documents submitted by the | 7 |
| health carrier, the covered person, the covered | 8 |
| person's authorized representative, or the covered | 9 |
| person's treating provider; | 10 |
| (D) the terms of coverage under the covered | 11 |
| person's health benefit plan with the health carrier to | 12 |
| ensure that the independent review organization's | 13 |
| decision is not contrary to the terms of coverage under | 14 |
| the covered person's health benefit plan with the | 15 |
| health carrier; | 16 |
| (E) the most appropriate practice guidelines, | 17 |
| which shall include applicable evidence-based | 18 |
| standards and may include any other practice | 19 |
| guidelines developed by the federal government, | 20 |
| national or professional medical societies, boards, | 21 |
| and associations; | 22 |
| (F) any applicable clinical review criteria | 23 |
| developed and used by the health carrier or its | 24 |
| designee utilization review organization; and | 25 |
| (G) the opinion of the independent review | 26 |
| organization's clinical reviewer or reviewers after |
|
|
|
09600SB1506sam002 |
- 24 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| considering paragraphs (A) through (G) of this item (1) | 2 |
| of this subsection (i) to the extent the information or | 3 |
| documents are available and the clinical reviewer or | 4 |
| reviewers considers the information or documents | 5 |
| appropriate; | 6 |
| (2) for an adverse determination or final adverse | 7 |
| determination that involves a denial of coverage based on a | 8 |
| determination that the health care service or treatment | 9 |
| recommended or requested is experimental or | 10 |
| investigational: | 11 |
| (A) the covered person's pertinent medical | 12 |
| records; | 13 |
| (B) the covered person's health care provider's | 14 |
| recommendation; | 15 |
| (C) consulting reports from appropriate health | 16 |
| care providers and other documents submitted by the | 17 |
| health
carrier, the covered person, the covered | 18 |
| person's
authorized representative, or the covered | 19 |
| person's treating physician or health care | 20 |
| professional; | 21 |
| (D) the terms of coverage under the covered | 22 |
| person's health benefit plan with the health carrier to | 23 |
| ensure that, but for the health carrier's | 24 |
| determination that the recommended or requested health | 25 |
| care service or treatment that is the subject of the | 26 |
| opinion is experimental or investigational, the |
|
|
|
09600SB1506sam002 |
- 25 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| independent review organization's opinion is not | 2 |
| contrary to the terms of coverage under the covered | 3 |
| person's health benefit plan with the health carrier; | 4 |
| and | 5 |
| (E) whether and to what extent:
| 6 |
| (i) the recommended or requested health care | 7 |
| service or treatment has been approved by the | 8 |
| federal Food and Drug Administration, if | 9 |
| applicable, for the condition; or | 10 |
| (ii) medical or scientific evidence or | 11 |
| evidence-based standards demonstrate that the | 12 |
| expected benefits of the recommended or requested | 13 |
| health care service or treatment is more likely | 14 |
| than not to be beneficial to the covered person | 15 |
| than any available standard health care service or | 16 |
| treatment and the adverse risks of the recommended | 17 |
| or requested health care service or treatment | 18 |
| would not be substantially increased over those of | 19 |
| available standard health care services or | 20 |
| treatments; or | 21 |
| (3) except for an expedited external review, for an | 22 |
| adverse determination or final adverse determination that | 23 |
| involves a denial of coverage based on a determination that | 24 |
| the health care service or treatment recommended or | 25 |
| requested is experimental or investigational, each | 26 |
| clinical reviewer selected by the independent review |
|
|
|
09600SB1506sam002 |
- 26 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| organization shall provide its opinion to the independent | 2 |
| review organization in writing and include the following | 3 |
| information:
| 4 |
| (A) a description of the covered person's medical | 5 |
| condition; | 6 |
| (B) a description of the indicators relevant to | 7 |
| determining whether there is sufficient evidence to | 8 |
| demonstrate that the recommended or requested health | 9 |
| care service or treatment is more likely than not to be | 10 |
| beneficial to the covered person than any available | 11 |
| standard health care services or treatments and the | 12 |
| adverse risks of the recommended or requested health | 13 |
| care service or treatment would not be substantially | 14 |
| increased over those of available standard health care | 15 |
| services or treatments;
| 16 |
| (C) a description and analysis of any medical or | 17 |
| scientific evidence considered in reaching the | 18 |
| opinion; | 19 |
| (D) a description and analysis of any | 20 |
| evidence-based standard; and | 21 |
| (E) information on whether the reviewer's | 22 |
| rationale for the opinion is based on paragraphs (i) or | 23 |
| (ii) of subitem (E) of item (2) of this subsection (i). | 24 |
| (j) Within 5 days after the date of receipt of all | 25 |
| necessary information, the assigned independent review | 26 |
| organization shall provide written notice of its decision to |
|
|
|
09600SB1506sam002 |
- 27 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| uphold or reverse the adverse determination or the final | 2 |
| adverse determination to the health carrier, the covered person | 3 |
| and, if applicable, the covered person's authorized | 4 |
| representative. In reaching a decision, the assigned | 5 |
| independent review organization is not bound by any decisions | 6 |
| or conclusions reached during the health carrier's utilization | 7 |
| review process as set forth by the American Accreditation | 8 |
| Health Care Commission. In such cases, the following provisions | 9 |
| shall apply: | 10 |
| (1) The independent review organization shall include | 11 |
| in the notice: | 12 |
| (A) a general description of the reason for the | 13 |
| request for external review; | 14 |
| (B) the date the independent review organization | 15 |
| received the assignment from the health carrier to | 16 |
| conduct the external review; | 17 |
| (C) the time period during which the external | 18 |
| review was conducted; | 19 |
| (D) references to the evidence or documentation, | 20 |
| including the evidence-based standards, considered in | 21 |
| reaching its decision. | 22 |
| (E) the date of its decision; and | 23 |
| (F) the principal reason or reasons for its | 24 |
| decision, including what applicable, if any, | 25 |
| evidence-based standards that were a basis for its | 26 |
| decision.
|
|
|
|
09600SB1506sam002 |
- 28 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| (2) For reviews of experimental or investigational | 2 |
| treatments, the notice shall include the following | 3 |
| information: | 4 |
| (A) a general description of the reason for the | 5 |
| request for external review; | 6 |
| (B) the written opinion of each clinical reviewer, | 7 |
| including the recommendation of each clinical reviewer | 8 |
| as to whether the recommended or requested health care | 9 |
| service or treatment should be covered and the | 10 |
| rationale for the reviewer's recommendation; | 11 |
| (C) the date that the independent review | 12 |
| organization received assignment from the health | 13 |
| carrier to conduct the external review; | 14 |
| (D) the time period during which the external | 15 |
| review was conducted; and | 16 |
| (E) the principal reason or reasons for its | 17 |
| decision. | 18 |
| (3) Upon receipt of a notice of a decision reversing | 19 |
| the adverse determination or final adverse determination, | 20 |
| the health carrier immediately shall approve the coverage | 21 |
| that was the subject of the adverse determination or final | 22 |
| adverse determination. | 23 |
| Section 40. Expedited external review. | 24 |
| (a) A covered person or a covered person's authorized | 25 |
| representative may file a request for an expedited external |
|
|
|
09600SB1506sam002 |
- 29 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| review with the health carrier either orally or in writing at | 2 |
| the time the covered person receives: | 3 |
| (1) an adverse determination, if: | 4 |
| (A) the adverse determination involves a medical | 5 |
| condition of the covered person for which the timeframe | 6 |
| for completion of an expedited internal review of a | 7 |
| grievance involving an adverse determination as set | 8 |
| forth by the American Accreditation Health Care | 9 |
| Commission would seriously jeopardize the life or | 10 |
| health of the covered person or would jeopardize the | 11 |
| covered person's ability to regain maximum function; | 12 |
| and | 13 |
| (B) the covered person or the covered person's | 14 |
| authorized representative has filed a request for an | 15 |
| expedited review of a grievance involving an adverse | 16 |
| determination as set forth by the American | 17 |
| Accreditation Health Care Commission; or | 18 |
| (2) a final adverse determination, if: | 19 |
| (A) the covered person has a medical condition | 20 |
| where the timeframe for completion of a standard | 21 |
| external review would seriously jeopardize the life or | 22 |
| health of the covered person or would jeopardize the | 23 |
| covered person's ability to regain maximum function; | 24 |
| or | 25 |
| (B) the final adverse determination concerns an | 26 |
| admission, availability of care, continued stay, or |
|
|
|
09600SB1506sam002 |
- 30 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| health care service for which the covered person | 2 |
| received emergency services but has not been | 3 |
| discharged from a facility. | 4 |
| (b) Upon receipt of a request for an expedited external | 5 |
| review as provided in Section 20 of this Act, the health | 6 |
| carrier shall determine whether the request meets the | 7 |
| reviewability requirements set forth in subsection (b) of | 8 |
| Section 35 of this Act. The health carrier shall immediately | 9 |
| notify the covered person and, if applicable, the covered | 10 |
| person's authorized representative of its eligibility | 11 |
| determination. The notice of initial determination shall | 12 |
| include a statement informing the covered person and, if | 13 |
| applicable, the covered person's authorized representative | 14 |
| that a health carrier's initial determination that an external | 15 |
| review request is ineligible for review may be appealed to the | 16 |
| Director. | 17 |
| (c) The Director may determine that a request is eligible | 18 |
| for external review under subsection (b) of Section 35 of this | 19 |
| Act, notwithstanding a health carrier's initial determination | 20 |
| that the request is ineligible and require that it be referred | 21 |
| for external review. In making a determination, the Director's | 22 |
| decision shall be made in accordance with the terms of the | 23 |
| covered person's health benefit plan and shall be subject to | 24 |
| all applicable provisions of this Act. | 25 |
| (d) Whenever a request is eligible for external review, the | 26 |
| health carrier shall immediately assign an independent review |
|
|
|
09600SB1506sam002 |
- 31 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| organization from the list of approved independent review | 2 |
| organizations compiled and maintained by the Director to | 3 |
| conduct the expedited review. In such cases, the following | 4 |
| provisions shall apply: | 5 |
| (1) The assignment by the health carrier of an approved | 6 |
| independent review organization to conduct an external | 7 |
| review in accordance with this Section shall be done on a | 8 |
| random basis among those approved independent review | 9 |
| organizations except as may be prohibited by conflict of | 10 |
| interest concerns pursuant to Section 60 of this Act.
| 11 |
| (2) Immediately upon assigning an independent review | 12 |
| organization to perform an expedited external review, but | 13 |
| in no case less than 24 hours after assigning the | 14 |
| independent review organization, the health carrier or its | 15 |
| designee utilization review organization shall provide or | 16 |
| transmit all necessary documents and information | 17 |
| considered in making the final adverse determination to the | 18 |
| assigned independent review organization electronically or | 19 |
| by telephone or facsimile or any other available | 20 |
| expeditious method. | 21 |
| (3) 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. |
|
|
|
09600SB1506sam002 |
- 32 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| (4) 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 (d), 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 |
| (e) In addition to the documents and information provided | 10 |
| by the health carrier or its utilization review organization | 11 |
| and any documents and information provided by the covered | 12 |
| person and the covered person's authorized representative, the | 13 |
| independent review organization shall consider the following | 14 |
| in reaching a decision: | 15 |
| (1) for an adverse determination or final adverse | 16 |
| determination, the provisions included in subitems (A) | 17 |
| through (G) of item (1) of subsection (i) of Section 35 of | 18 |
| this Act; or | 19 |
| (2) for an adverse determination or final adverse | 20 |
| determination that involves a denial of coverage based on a | 21 |
| determination that the health care service or treatment | 22 |
| recommended or requested is experimental or | 23 |
| investigational, the provisions included in subitems (A) | 24 |
| through (E) of item (2) of subsection (i) of Section 35 of | 25 |
| this Act. | 26 |
| (f) As expeditiously as the covered person's medical |
|
|
|
09600SB1506sam002 |
- 33 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| condition or circumstances requires, but in no event more than | 2 |
| 72 hours after the receipt of all pertinent information, the | 3 |
| assigned independent review organization shall: | 4 |
| (1) make a decision to uphold or reverse the final | 5 |
| adverse determination; and | 6 |
| (2) notify the health carrier, the covered person, the | 7 |
| covered person's health care provider, and if applicable, | 8 |
| the covered person's authorized representative, of the | 9 |
| decision. | 10 |
| (g) In reaching a decision, the assigned independent review | 11 |
| organization is not bound by any decisions or conclusions | 12 |
| reached during the health carrier's utilization review process | 13 |
| or the health carrier's internal grievance process as set forth | 14 |
| by the American Accreditation Health Care Commission.
| 15 |
| (h) Upon receipt of notice of a decision reversing the | 16 |
| final adverse determination, the health carrier shall | 17 |
| immediately approve the coverage that was the subject of the | 18 |
| final adverse determination. Within 48 hours after the date of | 19 |
| providing the notice required in this subsection (h), the | 20 |
| assigned independent review organization shall provide written | 21 |
| confirmation of the decision to the health carrier, the covered | 22 |
| person, and if applicable, the covered person's authorized | 23 |
| representative including the information set forth in | 24 |
| subsection (j) of Section 35 of this Act as applicable. | 25 |
| (i) An expedited external review may not be provided for | 26 |
| retrospective adverse or final adverse determinations. |
|
|
|
09600SB1506sam002 |
- 34 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| Section 45. Binding nature of external review decision. An | 2 |
| external review decision is binding on the health carrier. An | 3 |
| external review decision is binding on the covered person | 4 |
| except to the extent the covered person has other remedies | 5 |
| available under applicable federal or State law. A covered | 6 |
| person or the covered person's authorized representative may | 7 |
| not file a subsequent request for external review involving the | 8 |
| same adverse determination or final adverse determination for | 9 |
| which the covered person has already received an external | 10 |
| review decision pursuant to this Act.
| 11 |
| Section 50. Approval of independent review organizations. | 12 |
| (a) The Director shall approve independent review | 13 |
| organizations eligible to be assigned to conduct external | 14 |
| reviews under this Act. | 15 |
| (b) In order to be eligible for approval by the Director | 16 |
| under this Section to conduct external reviews under this Act | 17 |
| an independent review organization:
| 18 |
| (1) except as otherwise provided in this Section, shall | 19 |
| be accredited by a nationally recognized private | 20 |
| accrediting entity that the Director has determined has | 21 |
| independent review organization accreditation standards | 22 |
| that are equivalent to or exceed the minimum qualifications | 23 |
| for independent review; and | 24 |
| (2) shall submit an application for approval in |
|
|
|
09600SB1506sam002 |
- 35 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| accordance with subsection (d) of this Section.
| 2 |
| (c) The Director shall develop an application form for | 3 |
| initially approving and for reapproving independent review | 4 |
| organizations to conduct external reviews. | 5 |
| (d) Any independent review organization wishing to be | 6 |
| approved to conduct external reviews under this Act shall | 7 |
| submit the application form and include with the form all | 8 |
| documentation and information necessary for the Director to | 9 |
| determine if the independent review organization satisfies the | 10 |
| minimum qualifications established under this Act.
The | 11 |
| Director may: | 12 |
| (1) approve independent review organizations that are | 13 |
| not accredited by a nationally recognized private | 14 |
| accrediting entity if there are no acceptable nationally | 15 |
| recognized private accrediting entities providing | 16 |
| independent review organization accreditation; and | 17 |
| (2) by rule establish an application fee that | 18 |
| independent review organizations shall submit to the | 19 |
| Director with an application for approval and renewing.
| 20 |
| (e) An approval is effective for 2 years, unless the | 21 |
| Director determines before its expiration that the independent | 22 |
| review organization is not satisfying the minimum | 23 |
| qualifications established under this Act. | 24 |
| (f) Whenever the Director determines that an independent | 25 |
| review organization has lost its accreditation or no longer | 26 |
| satisfies the minimum requirements established under this Act, |
|
|
|
09600SB1506sam002 |
- 36 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| the Director shall terminate the approval of the independent | 2 |
| review organization and remove the independent review | 3 |
| organization from the list of independent review organizations | 4 |
| approved to conduct external reviews under this Act that is | 5 |
| maintained by the Director. | 6 |
| (g) The Director shall maintain and periodically update a | 7 |
| list of approved independent review organizations. | 8 |
| (h) The Director may promulgate regulations to carry out | 9 |
| the provisions of this Section. | 10 |
| Section 55. Minimum qualifications for independent review | 11 |
| organizations.
| 12 |
| (a) To be approved to conduct external reviews, an | 13 |
| independent review organization shall have and maintain | 14 |
| written policies and procedures that govern all aspects of both | 15 |
| the standard external review process and the expedited external | 16 |
| review process set forth in this Act that include, at a | 17 |
| minimum: | 18 |
| (1) a quality assurance mechanism that ensures that: | 19 |
| (A) external reviews are conducted within the | 20 |
| specified time frames and required notices are | 21 |
| provided in a timely manner; | 22 |
| (B) selection of qualified and impartial clinical | 23 |
| reviewers to conduct external reviews on behalf of the | 24 |
| independent review organization and suitable matching | 25 |
| of reviewers to specific cases and that the independent |
|
|
|
09600SB1506sam002 |
- 37 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| review organization employs or contracts with an | 2 |
| adequate number of clinical reviewers to meet this | 3 |
| objective; | 4 |
| (C) the health carrier, the covered person, and the | 5 |
| covered person's authorized representative shall not | 6 |
| choose or control the choice of the physicians or other | 7 |
| health care professionals to be selected to conduct the | 8 |
| external review; | 9 |
| (D) confidentiality of medical and treatment | 10 |
| records and clinical review criteria; and | 11 |
| (E) any person employed by or under contract with | 12 |
| the independent review organization adheres to the | 13 |
| requirements of this Act; | 14 |
| (2) a toll-free telephone service operating on a | 15 |
| 24-hour-day, 7-day-a-week basis that accepts, receives, | 16 |
| and records information related to external reviews and | 17 |
| provides appropriate instructions; and | 18 |
| (3) an agreement to maintain and provide to the | 19 |
| Director the information set out in Section 70 of this Act. | 20 |
| (b) All clinical reviewers assigned by an independent | 21 |
| review organization to conduct external reviews shall be | 22 |
| physicians or other appropriate health care providers who meet | 23 |
| the following minimum qualifications:
| 24 |
| (1) be an expert in the treatment of the covered | 25 |
| person's medical condition that is the subject of the | 26 |
| external review; |
|
|
|
09600SB1506sam002 |
- 38 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| (2) be knowledgeable about the recommended health care | 2 |
| service or treatment through recent or current actual | 3 |
| clinical experience treating patients with the same or | 4 |
| similar medical condition of the covered person; | 5 |
| (3) hold a non-restricted license in a state of the | 6 |
| United States and, for physicians, a current certification | 7 |
| by a recognized American medical specialty board in the | 8 |
| area or areas appropriate to the subject of the external | 9 |
| review; | 10 |
| (4) have no history of disciplinary actions or | 11 |
| sanctions, including loss of staff privileges or | 12 |
| participation restrictions, that have been taken or are | 13 |
| pending by any hospital, governmental agency or unit, or | 14 |
| regulatory body that raise a substantial question as to the | 15 |
| clinical reviewer's physical, mental, or professional | 16 |
| competence or moral character; and | 17 |
| (5) for purposes of conducting an external review of | 18 |
| experimental or investigational treatment adverse | 19 |
| determinations, through clinical experience in the past 3 | 20 |
| years, be an expert in the treatment of the covered | 21 |
| person's condition and knowledgeable about the recommended | 22 |
| or requested health care service or treatment; neither the | 23 |
| covered person, the covered person's authorized | 24 |
| representative, if applicable, nor the health carrier | 25 |
| shall choose or control the choice of the physicians or | 26 |
| other health care professionals selected to conduct the |
|
|
|
09600SB1506sam002 |
- 39 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| external review. | 2 |
| (c) In addition to the requirements set forth in subsection | 3 |
| (a), an independent review organization may not own or control, | 4 |
| be a subsidiary of, or in any way be owned, or controlled by, | 5 |
| or exercise control with a health benefit plan, a national, | 6 |
| State, or local trade association of health benefit plans, or a | 7 |
| national, State, or local trade association of health care | 8 |
| providers. | 9 |
| (d) Conflicts of interest prohibited.
In addition to the | 10 |
| requirements set forth in subsections (a), (b), and (c) of this | 11 |
| Section, to be approved pursuant to this Act to conduct an | 12 |
| external review of a specified case, neither the independent | 13 |
| review organization selected to conduct the external review nor | 14 |
| any clinical reviewer assigned by the independent organization | 15 |
| to conduct the external review may have a material | 16 |
| professional, familial or financial conflict of interest with | 17 |
| any of the following: | 18 |
| (1) the health carrier that is the subject of the | 19 |
| external review; | 20 |
| (2) the covered person whose treatment is the subject | 21 |
| of the external review or the covered person's authorized | 22 |
| representative; | 23 |
| (3) any officer, director or management employee of the | 24 |
| health carrier that is the subject of the external review; | 25 |
| (4) the health care provider, the health care | 26 |
| provider's medical group or independent practice |
|
|
|
09600SB1506sam002 |
- 40 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| association recommending the health care service or | 2 |
| treatment that is the subject of the external review; | 3 |
| (5) the facility at which the recommended health care | 4 |
| service or treatment would be provided; or | 5 |
| (6) the developer or manufacturer of the principal | 6 |
| drug, device, procedure, or other therapy being | 7 |
| recommended for the covered person whose treatment is the | 8 |
| subject of the external review.
| 9 |
| (e) An independent review organization that is accredited | 10 |
| by a nationally recognized private accrediting entity that has | 11 |
| independent review accreditation standards that the Director | 12 |
| has determined are equivalent to or exceed the minimum | 13 |
| qualifications of this Section shall be presumed to be in | 14 |
| compliance with this Section and shall be eligible for approval | 15 |
| under this Section. | 16 |
| (f) An independent review organization shall be unbiased. | 17 |
| An independent review organization shall establish and | 18 |
| maintain written procedures to ensure that it is unbiased in | 19 |
| addition to any other procedures required under this Section.
| 20 |
| Section 60. Hold harmless for independent review | 21 |
| organizations. No independent review organization or clinical | 22 |
| reviewer working on behalf of an independent review | 23 |
| organization or an employee, agent or contractor of an | 24 |
| independent review organization shall be liable for damages to | 25 |
| any person for any opinions rendered or acts or omissions |
|
|
|
09600SB1506sam002 |
- 41 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| performed within the scope of the organization's or person's | 2 |
| duties under the law during or upon completion of an external | 3 |
| review conducted pursuant to this Act, unless the opinion was | 4 |
| rendered or act or omission performed in bad faith or involved | 5 |
| gross negligence. | 6 |
| Section 65. External review reporting requirements. | 7 |
| (a) Each health carrier shall maintain written records in | 8 |
| the aggregate on all requests for external review for each | 9 |
| calendar year and submit a report to the Director in the format | 10 |
| specified by the Director by March 1 of each year. | 11 |
| (b) The report shall include in the aggregate:
| 12 |
| (1) the total number of requests for external review; | 13 |
| (2) the total number of requests for expedited external | 14 |
| review;
| 15 |
| (3) the total number of requests for external review | 16 |
| denied; | 17 |
| (4) the number of requests for external review | 18 |
| resolved, including: | 19 |
| (A) the number of requests for external review | 20 |
| resolved upholding the adverse determination or final | 21 |
| adverse determination; | 22 |
| (B) the number of requests for external review | 23 |
| resolved reversing the adverse determination or final | 24 |
| adverse determination; | 25 |
| (C) the number of requests for expedited external |
|
|
|
09600SB1506sam002 |
- 42 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| review resolved upholding the adverse determination or | 2 |
| final adverse determination; and | 3 |
| (D) the number of requests for expedited external | 4 |
| review resolved reversing the adverse determination or | 5 |
| final adverse determination; | 6 |
| (5) the average length of time for resolution for an | 7 |
| external review; | 8 |
| (6) the average length of time for resolution for an | 9 |
| expedited external review; | 10 |
| (7) a summary of the types of coverages or cases for | 11 |
| which an external review was sought, as specified below:
| 12 |
| (A) denial of care or treatment (dissatisfaction | 13 |
| regarding prospective non-authorization of a request | 14 |
| for care or treatment recommended by a provider | 15 |
| excluding diagnostic procedures and referral requests; | 16 |
| partial approvals and care terminations are also | 17 |
| considered to be denials); | 18 |
| (B) denial of diagnostic procedure | 19 |
| (dissatisfaction regarding prospective | 20 |
| non-authorization of a request for a diagnostic | 21 |
| procedure recommended by a provider; partial approvals | 22 |
| are also considered to be denials); | 23 |
| (C) denial of referral request (dissatisfaction | 24 |
| regarding non-authorization of a request for a | 25 |
| referral to another provider recommended by a PCP); | 26 |
| (D) claims and utilization review (dissatisfaction |
|
|
|
09600SB1506sam002 |
- 43 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| regarding the concurrent or retrospective evaluation | 2 |
| of the coverage, medical necessity, efficiency or | 3 |
| appropriateness of health care services or treatment | 4 |
| plans; prospective "Denials of care or treatment," | 5 |
| "Denials of diagnostic procedures" and "Denials of | 6 |
| referral requests" should not be classified in this | 7 |
| category, but the appropriate one above);
| 8 |
| (8) the number of external reviews that were terminated | 9 |
| as the result of a reconsideration by the health carrier of | 10 |
| its adverse determination or final adverse determination | 11 |
| after the receipt of additional information from the | 12 |
| covered person or the covered person's authorized | 13 |
| representative; and | 14 |
| (9) any other information the Director may request or | 15 |
| require.
| 16 |
| Section 70. Funding of external review. The health carrier | 17 |
| shall be solely responsible for paying the cost of external | 18 |
| reviews conducted by independent review organizations. | 19 |
| Section 75. Disclosure requirements. | 20 |
| (a) Each health carrier shall include a description of the | 21 |
| external review procedures in, or attached to, the policy, | 22 |
| certificate, membership booklet, and outline of coverage or | 23 |
| other evidence of coverage it provides to covered persons. | 24 |
| (b) The description required under subsection (a) of this |
|
|
|
09600SB1506sam002 |
- 44 - |
LRB096 10769 RPM 24366 a |
|
| 1 |
| Section shall include a statement that informs the covered | 2 |
| person of the right of the covered person to file a request for | 3 |
| an external review of an adverse determination or final adverse | 4 |
| determination with the health carrier. The statement shall | 5 |
| explain that external review is available when the adverse | 6 |
| determination or final adverse determination involves an issue | 7 |
| of medical necessity, appropriateness, health care setting, | 8 |
| level of care, or effectiveness. The statement shall include | 9 |
| the toll-free telephone number and address of the Office of | 10 |
| Consumer Health Insurance within the Division of Insurance.
| 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.".
|
|