Full Text of HB5079 96th General Assembly
HB5079enr 96TH GENERAL ASSEMBLY
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 5. The Health Carrier External Review Act is | 5 |
| amended by changing Section 35 as follows: | 6 |
| (215 ILCS 180/35) | 7 |
| (This Section may contain text from a Public Act with a | 8 |
| delayed effective date )
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| Sec. 35. Standard external review. | 10 |
| (a) Within 4 months after the date of receipt of a notice | 11 |
| of an adverse determination or final adverse determination, a | 12 |
| covered person or the covered person's authorized | 13 |
| representative may file a request for an external review with | 14 |
| the health carrier. | 15 |
| (b) Within 5 business days following the date of receipt of | 16 |
| the external review request, the health carrier shall complete | 17 |
| a preliminary review of the request to determine whether:
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| (1) the individual is or was a covered person in the | 19 |
| health benefit plan at the time the health care service was | 20 |
| requested or at the time the health care service was | 21 |
| provided; | 22 |
| (2) the health care service that is the subject of the | 23 |
| adverse determination or the final adverse determination |
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| is a covered service under the covered person's health | 2 |
| benefit plan, but the health carrier has determined that | 3 |
| the health care service is not covered because it does not | 4 |
| meet the health carrier's requirements for medical | 5 |
| necessity, appropriateness, health care setting, level of | 6 |
| care, or effectiveness; | 7 |
| (3) the covered person has exhausted the health | 8 |
| carrier's internal grievance process as set forth in this | 9 |
| Act; | 10 |
| (4) for appeals relating to a determination based on | 11 |
| treatment being experimental or investigational, the | 12 |
| requested health care service or treatment that is the | 13 |
| subject of the adverse determination or final adverse | 14 |
| determination is a covered benefit under the covered | 15 |
| person's health benefit plan except for the health | 16 |
| carrier's determination that the service or treatment is | 17 |
| experimental or investigational for a particular medical | 18 |
| condition and is not explicitly listed as an excluded | 19 |
| benefit under the covered person's health benefit plan with | 20 |
| the health carrier and that the covered person's health | 21 |
| care provider, who ordered or provided the services in | 22 |
| question and who is licensed under the
Medical Practice Act | 23 |
| of 1987 is a physician licensed to practice medicine in all | 24 |
| its branches , has certified that one of the following | 25 |
| situations is applicable: | 26 |
| (A) standard health care services or treatments |
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| have not been effective in improving the condition of | 2 |
| the covered person; | 3 |
| (B) standard health care services or treatments | 4 |
| are not medically appropriate for the covered person; | 5 |
| (C) there is no available standard health care | 6 |
| service or treatment covered by the health carrier that | 7 |
| is more beneficial than the recommended or requested | 8 |
| health care service or treatment;
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| (D) the health care service or treatment is likely | 10 |
| to be more beneficial to the covered person, in the | 11 |
| health care provider's opinion, than any available | 12 |
| standard health care services or treatments; or | 13 |
| (E) that scientifically valid studies using | 14 |
| accepted protocols demonstrate that the health care | 15 |
| service or treatment requested is likely to be more | 16 |
| beneficial to the covered person than any available | 17 |
| standard health care services or treatments; and | 18 |
| (5) the covered person has provided all the information | 19 |
| and forms required to process an external review, as | 20 |
| specified in this Act. | 21 |
| (c) Within one business day after completion of the | 22 |
| preliminary review, the health carrier shall notify the covered | 23 |
| person and, if applicable, the covered person's authorized | 24 |
| representative in writing whether the request is complete and | 25 |
| eligible for external review. If the request: | 26 |
| (1) is not complete, the health carrier shall inform |
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| the covered person and, if applicable, the covered person's | 2 |
| authorized representative in writing and include in the | 3 |
| notice what information or materials are required by this | 4 |
| Act to make the request complete; or | 5 |
| (2) is not eligible for external review, the health | 6 |
| carrier shall inform the covered person and, if applicable, | 7 |
| the covered person's authorized representative in writing | 8 |
| and include in the notice the reasons for its | 9 |
| ineligibility.
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| The notice of initial determination of ineligibility shall | 11 |
| include a statement informing the covered person and, if | 12 |
| applicable, the covered person's authorized representative | 13 |
| that a health carrier's initial determination that the external | 14 |
| review request is ineligible for review may be appealed to the | 15 |
| Director by filing a complaint with the Director. | 16 |
| Notwithstanding a health carrier's initial determination | 17 |
| that the request is ineligible for external review, the | 18 |
| Director may determine that a request is eligible for external | 19 |
| review and require that it be referred for external review. In | 20 |
| making such determination, the Director's decision shall be in | 21 |
| accordance with the terms of the covered person's health | 22 |
| benefit plan and shall be subject to all applicable provisions | 23 |
| of this Act. | 24 |
| (d) Whenever a request is eligible for external review the | 25 |
| health carrier shall, within 5 business days: | 26 |
| (1) assign an independent review organization from the |
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| list of approved independent review organizations compiled | 2 |
| and maintained by the Director; and | 3 |
| (2) notify in writing the covered person and, if | 4 |
| applicable, the covered person's authorized representative | 5 |
| of the request's eligibility and acceptance for external | 6 |
| review and the name of the independent review organization. | 7 |
| The health carrier shall include in the notice provided to | 8 |
| the covered person and, if applicable, the covered person's | 9 |
| authorized representative a statement that the covered person | 10 |
| or the covered person's authorized representative may, within 5 | 11 |
| business days following the date of receipt of the notice | 12 |
| provided pursuant to item (2) of this subsection (d), submit in | 13 |
| writing to the assigned independent review organization | 14 |
| additional information that the independent review | 15 |
| organization shall consider when conducting the external | 16 |
| review. The independent review organization is not required to, | 17 |
| but may, accept and consider additional information submitted | 18 |
| after 5 business days. | 19 |
| (e) The assignment of an approved independent review | 20 |
| organization to conduct an external review in accordance with | 21 |
| this Section shall be made from those approved independent | 22 |
| review organizations qualified to conduct external review as | 23 |
| required by Sections 50 and 55 of this Act. | 24 |
| (f) Upon assignment of an independent review organization, | 25 |
| the health carrier or its designee utilization review | 26 |
| organization shall, within 5 business days, provide to the |
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| assigned independent review organization the documents and any | 2 |
| information considered in making the adverse determination or | 3 |
| final adverse determination; in such cases, the following | 4 |
| provisions shall apply: | 5 |
| (1) Except as provided in item (2) of this subsection | 6 |
| (f), failure by the health carrier or its utilization | 7 |
| review organization to provide the documents and | 8 |
| information within the specified time frame shall not delay | 9 |
| the conduct of the external review. | 10 |
| (2) If the health carrier or its utilization review | 11 |
| organization fails to provide the documents and | 12 |
| information within the specified time frame, the assigned | 13 |
| independent review organization may terminate the external | 14 |
| review and make a decision to reverse the adverse | 15 |
| determination or final adverse determination. | 16 |
| (3) Within one business day after making the decision | 17 |
| to terminate the external review and make a decision to | 18 |
| reverse the adverse determination or final adverse | 19 |
| determination under item (2) of this subsection (f), the | 20 |
| independent review organization shall notify the health | 21 |
| carrier, the covered person and, if applicable, the covered | 22 |
| person's authorized representative, of its decision to | 23 |
| reverse the adverse determination. | 24 |
| (g) Upon receipt of the information from the health carrier | 25 |
| or its utilization review organization, the assigned | 26 |
| independent review organization shall review all of the |
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| information and documents and any other information submitted | 2 |
| in writing to the independent review organization by the | 3 |
| covered person and the covered person's authorized | 4 |
| representative. | 5 |
| (h) Upon receipt of any information submitted by the | 6 |
| covered person or the covered person's authorized | 7 |
| representative, the independent review organization shall | 8 |
| forward the information to the health carrier within 1 business | 9 |
| day. | 10 |
| (1) Upon receipt of the information, if any, the health | 11 |
| carrier may reconsider its adverse determination or final | 12 |
| adverse determination that is the subject of the external | 13 |
| review.
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| (2) Reconsideration by the health carrier of its | 15 |
| adverse determination or final adverse determination shall | 16 |
| not delay or terminate the external review.
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| (3) The external review may only be terminated if the | 18 |
| health carrier decides, upon completion of its | 19 |
| reconsideration, to reverse its adverse determination or | 20 |
| final adverse determination and provide coverage or | 21 |
| payment for the health care service that is the subject of | 22 |
| the adverse determination or final adverse determination. | 23 |
| In such cases, the following provisions shall apply: | 24 |
| (A) Within one business day after making the | 25 |
| decision to reverse its adverse determination or final | 26 |
| adverse determination, the health carrier shall notify |
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| the covered person and if applicable, the covered | 2 |
| person's authorized representative, and the assigned | 3 |
| independent review organization in writing of its | 4 |
| decision. | 5 |
| (B) Upon notice from the health carrier that the | 6 |
| health carrier has made a decision to reverse its | 7 |
| adverse determination or final adverse determination, | 8 |
| the assigned independent review organization shall | 9 |
| terminate the external review. | 10 |
| (i) In addition to the documents and information provided | 11 |
| by the health carrier or its utilization review organization | 12 |
| and the covered person and the covered person's authorized | 13 |
| representative, if any, the independent review organization, | 14 |
| to the extent the information or documents are available and | 15 |
| the independent review organization considers them | 16 |
| appropriate, shall consider the following in reaching a | 17 |
| decision: | 18 |
| (1) the covered person's pertinent medical records; | 19 |
| (2) the covered person's health care provider's | 20 |
| recommendation; | 21 |
| (3) consulting reports from appropriate health care | 22 |
| providers and other documents submitted by the health | 23 |
| carrier, the covered person, the covered person's | 24 |
| authorized representative, or the covered person's | 25 |
| treating provider; | 26 |
| (4) the terms of coverage under the covered person's |
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| health benefit plan with the health carrier to ensure that | 2 |
| the independent review organization's decision is not | 3 |
| contrary to the terms of coverage under the covered | 4 |
| person's health benefit plan with the health carrier; | 5 |
| (5) the most appropriate practice guidelines, which | 6 |
| shall include applicable evidence-based standards and may | 7 |
| include any other practice guidelines developed by the | 8 |
| federal government, national or professional medical | 9 |
| societies, boards, and associations; | 10 |
| (6) any applicable clinical review criteria developed | 11 |
| and used by the health carrier or its designee utilization | 12 |
| review organization; and | 13 |
| (7) the opinion of the independent review | 14 |
| organization's clinical reviewer or reviewers after | 15 |
| considering items (1) through (6) of this subsection (i) to | 16 |
| the extent the information or documents are available and | 17 |
| the clinical reviewer or reviewers considers the | 18 |
| information or documents appropriate; and | 19 |
| (8) for a denial of coverage based on a determination | 20 |
| that the health care service or treatment recommended or | 21 |
| requested is experimental or investigational, whether and | 22 |
| to what extent: | 23 |
| (A) the recommended or requested health care | 24 |
| service or treatment has been approved by the federal | 25 |
| Food and Drug Administration, if applicable, for the | 26 |
| condition; |
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| (B) medical or scientific evidence or | 2 |
| evidence-based standards demonstrate that the expected | 3 |
| benefits of the recommended or requested health care | 4 |
| service or treatment is more likely than not to be | 5 |
| beneficial to the covered person than any available | 6 |
| standard health care service or treatment and the | 7 |
| adverse risks of the recommended or requested health | 8 |
| care service or treatment would not be substantially | 9 |
| increased over those of available standard health care | 10 |
| services or treatments; or | 11 |
| (C) the terms of coverage under the covered | 12 |
| person's health benefit plan with the health carrier to | 13 |
| ensure that the health care service or treatment that | 14 |
| is the subject of the opinion is experimental or | 15 |
| investigational would otherwise be covered under the | 16 |
| terms of coverage of the covered person's health | 17 |
| benefit plan with the health carrier. | 18 |
| (j) Within 5 days after the date of receipt of all | 19 |
| necessary information, the assigned independent review | 20 |
| organization shall provide written notice of its decision to | 21 |
| uphold or reverse the adverse determination or the final | 22 |
| adverse determination to the health carrier, the covered person | 23 |
| and, if applicable, the covered person's authorized | 24 |
| representative. In reaching a decision, the assigned | 25 |
| independent review organization is not bound by any claim | 26 |
| determinations reached prior to the submission of information |
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| to the independent review organization. In such cases, the | 2 |
| following provisions shall apply: | 3 |
| (1) The independent review organization shall include | 4 |
| in the notice: | 5 |
| (A) a general description of the reason for the | 6 |
| request for external review; | 7 |
| (B) the date the independent review organization | 8 |
| received the assignment from the health carrier to | 9 |
| conduct the external review; | 10 |
| (C) the time period during which the external | 11 |
| review was conducted; | 12 |
| (D) references to the evidence or documentation, | 13 |
| including the evidence-based standards, considered in | 14 |
| reaching its decision; | 15 |
| (E) the date of its decision; and | 16 |
| (F) the principal reason or reasons for its | 17 |
| decision, including what applicable, if any, | 18 |
| evidence-based standards that were a basis for its | 19 |
| decision.
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| (2) For reviews of experimental or investigational | 21 |
| treatments, the notice shall include the following | 22 |
| information: | 23 |
| (A) a description of the covered person's medical | 24 |
| condition; | 25 |
| (B) a description of the indicators relevant to | 26 |
| whether there is sufficient evidence to demonstrate |
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| that the recommended or requested health care service | 2 |
| or treatment is more likely than not to be more | 3 |
| beneficial to the covered person than any available | 4 |
| standard health care services or treatments and the | 5 |
| adverse risks of the recommended or requested health | 6 |
| care service or treatment would not be substantially | 7 |
| increased over those of available standard health care | 8 |
| services or treatments; | 9 |
| (C) a description and analysis of any medical or | 10 |
| scientific evidence considered in reaching the | 11 |
| opinion; | 12 |
| (D) a description and analysis of any | 13 |
| evidence-based standards; | 14 |
| (E) whether the recommended or requested health | 15 |
| care service or treatment has been approved by the | 16 |
| federal Food and Drug Administration, for the | 17 |
| condition; | 18 |
| (F) whether medical or scientific evidence or | 19 |
| evidence-based standards demonstrate that the expected | 20 |
| benefits of the recommended or requested health care | 21 |
| service or treatment is more likely than not to be more | 22 |
| beneficial to the covered person than any available | 23 |
| standard health care service or treatment and the | 24 |
| adverse risks of the recommended or requested health | 25 |
| care service or treatment would not be substantially | 26 |
| increased over those of available standard health care |
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| services or treatments; and | 2 |
| (G) the written opinion of the clinical reviewer, | 3 |
| including the reviewer's recommendation as to whether | 4 |
| the recommended or requested health care service or | 5 |
| treatment should be covered and the rationale for the | 6 |
| reviewer's recommendation. | 7 |
| (3) In reaching a decision, the assigned independent | 8 |
| review organization is not bound by any decisions or | 9 |
| conclusions reached during the health carrier's | 10 |
| utilization review process or the health carrier's | 11 |
| internal grievance or appeals process. | 12 |
| (4) Upon receipt of a notice of a decision reversing | 13 |
| the adverse determination or final adverse determination, | 14 |
| the health carrier immediately shall approve the coverage | 15 |
| that was the subject of the adverse determination or final | 16 |
| adverse determination.
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| (Source: P.A. 96-857, eff. 7-1-10.)
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| Section 95. No acceleration or delay. Where this Act makes | 19 |
| changes in a statute that is represented in this Act by text | 20 |
| that is not yet or no longer in effect (for example, a Section | 21 |
| represented by multiple versions), the use of that text does | 22 |
| not accelerate or delay the taking effect of (i) the changes | 23 |
| made by this Act or (ii) provisions derived from any other | 24 |
| Public Act.
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