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215 ILCS 134/45
(215 ILCS 134/45)
Health care services appeals,
external independent reviews.
(a) A health care plan shall establish and maintain an appeals procedure as
outlined in this Act. Compliance with this Act's appeals procedures shall
satisfy a health care plan's obligation to provide appeal procedures under any
other State law or rules.
All appeals of a health care plan's administrative determinations and
complaints regarding its administrative decisions shall be handled as required
under Section 50.
(b) When an appeal concerns a decision or action by a health care plan,
employees, or its subcontractors that relates to (i) health care services,
including, but not limited to, procedures or
for an enrollee with an ongoing course of treatment ordered
by a health care provider,
the denial of which could significantly
increase the risk to an
or (ii) a treatment referral, service,
procedure, or other health care service,
the denial of which could significantly
increase the risk to an
the health care plan must allow for the filing of an appeal
either orally or in writing. Upon submission of the appeal, a health care plan
must notify the party filing the appeal, as soon as possible, but in no event
more than 24 hours after the submission of the appeal, of all information
that the plan requires to evaluate the appeal.
The health care plan shall render a decision on the appeal within
24 hours after receipt of the required information. The health care plan shall
notify the party filing the
appeal and the enrollee, enrollee's primary care physician, and any health care
provider who recommended the health care service involved in the appeal of its
followed-up by a written notice of the determination.
(c) For all appeals related to health care services including, but not
limited to, procedures or treatments for an enrollee and not covered by
subsection (b) above, the health care
plan shall establish a procedure for the filing of such appeals. Upon
submission of an appeal under this subsection, a health care plan must notify
the party filing an appeal, within 3 business days, of all information that the
plan requires to evaluate the appeal.
The health care plan shall render a decision on the appeal within 15 business
days after receipt of the required information. The health care plan shall
notify the party filing the appeal,
the enrollee, the enrollee's primary care physician, and any health care
who recommended the health care service involved in the appeal orally of its
decision followed-up by a written notice of the determination.
(d) An appeal under subsection (b) or (c) may be filed by the
enrollee, the enrollee's designee or guardian, the enrollee's primary care
physician, or the enrollee's health care provider. A health care plan shall
designate a clinical peer to review
appeals, because these appeals pertain to medical or clinical matters
and such an appeal must be reviewed by an appropriate
health care professional. No one reviewing an appeal may have had any
in the initial determination that is the subject of the appeal. The written
notice of determination required under subsections (b) and (c) shall
include (i) clear and detailed reasons for the determination, (ii)
the medical or
clinical criteria for the determination, which shall be based upon sound
clinical evidence and reviewed on a periodic basis, and (iii) in the case of an
adverse determination, the
procedures for requesting an external independent review as provided by the Illinois Health Carrier External Review Act.
(e) If an appeal filed under subsection (b) or (c) is denied for a reason
including, but not limited to, the
service, procedure, or treatment is not viewed as medically necessary,
denial of specific tests or procedures, denial of referral
to specialist physicians or denial of hospitalization requests or length of
stay requests, any involved party may request an external independent review as provided by the Illinois Health Carrier External Review Act.
(f) Until July 1, 2013, if an external independent review decision made pursuant to the Illinois Health Carrier External Review Act upholds a determination adverse to the covered person, the covered person has the right to appeal the final decision to the Department; if the external review decision is found by the Director to have been arbitrary and capricious, then the Director, with consultation from a licensed medical professional, may overturn the external review decision and require the health carrier to pay for the health care service
or treatment; such decision, if any, shall be made solely on
the legal or medical merits of the claim. If an external review decision is overturned by the Director pursuant to this Section and the health carrier so requests, then the Director shall assign a new independent review organization to reconsider the overturned decision. The new independent review organization shall follow subsection (d) of Section 40 of the Health Carrier External Review Act in rendering a decision.
(g) Future contractual or employment action by the health care plan
patient's physician or other health care provider shall not be based solely on
the physician's or other
health care provider's participation in health care services appeals,
external independent reviews under the Illinois Health Carrier External Review Act.
(h) Nothing in this Section shall be construed to require a health care
plan to pay for a health care service not covered under the enrollee's
certificate of coverage or policy.
(Source: P.A. 96-857, eff. 7-1-10