Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process.
Recent laws may not yet be included in the ILCS database, but they are found on this site as
Public
Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the
Guide.
Because the statute database is maintained primarily for legislative drafting purposes,
statutory changes are sometimes included in the statute database before they take effect.
If the source note at the end of a Section of the statutes includes a Public Act that has
not yet taken effect, the version of the law that is currently in effect may have already
been removed from the database and you should refer to that Public Act to see the changes
made to the current law.
(215 ILCS 134/70)
Sec. 70. Post-stabilization medical services.
(a) If prior authorization for covered post-stabilization services is
required by the health care
plan, the plan shall provide access 24 hours a day, 7 days a week to persons
designated by
the plan to make such determinations, provided that any determination made
under this Section must be made by a health care
professional. The review shall be resolved in accordance with the provisions
of Section 85 and the time requirements of this Section.
(a-5) Prior authorization or approval by the plan shall not be required for post-stabilization services that constitute emergency services under Section 356z.3a of the Illinois Insurance Code. (b) The treating physician licensed to practice medicine in all its branches
or health care provider shall contact the health care plan or
delegated health care provider as
designated on the enrollee's health insurance card to obtain
authorization, denial, or
arrangements for an alternate plan of treatment or transfer of the
enrollee.
(c) The treating physician licensed to practice medicine in all its
branches or
health care provider shall document in the enrollee's
medical record the enrollee's
presenting symptoms; emergency medical condition; and time, phone number
dialed,
and result of the communication for request for authorization of
post-stabilization medical services. The health care plan shall provide
reimbursement for covered
post-stabilization medical services if:
(1) authorization to render them is received from the |
| health care plan or its delegated health care provider, or
|
|
(2) after 2 documented good faith efforts, the
|
| treating health care provider has attempted to contact the enrollee's health care plan or its delegated health care provider, as designated on the enrollee's health insurance card, for prior authorization of post-stabilization medical services and neither the plan nor designated persons were accessible or the authorization was not denied within 60 minutes of the request. "Two documented good faith efforts" means the health care provider has called the telephone number on the enrollee's health insurance card or other available number either 2 times or one time and an additional call to any referral number provided. "Good faith" means honesty of purpose, freedom from intention to defraud, and being faithful to one's duty or obligation. For the purpose of this Act, good faith shall be presumed.
|
|
(d) After rendering any post-stabilization medical services,
the treating physician licensed to practice medicine
in all its branches or health care
provider shall continue to make every reasonable effort to contact the health
care plan
or its delegated health care provider regarding authorization, denial, or
arrangements
for an
alternate plan of treatment or transfer of the enrollee until the
treating health care provider
receives instructions from the health care plan or delegated health care
provider for
continued care or the care is transferred to another health care provider or
the patient is discharged.
(e) Payment for covered post-stabilization services may be denied:
(1) if the treating health care provider does not
|
| meet the conditions outlined in subsection (c);
|
|
(2) upon determination that the post-stabilization
|
| services claimed were not performed;
|
|
(3) upon timely determination that the
|
| post-stabilization services rendered were contrary to the instructions of the health care plan or its delegated health care provider if contact was made between those parties prior to the service being rendered;
|
|
(4) upon determination that the patient receiving
|
| such services was not an enrollee of the health care plan; or
|
|
(5) upon material misrepresentation by the enrollee
|
| or health care provider; "material" means a fact or situation that is not merely technical in nature and results or could result in a substantial change in the situation.
|
|
(f) Nothing in this Section prohibits a health care plan from delegating
tasks associated with the responsibilities enumerated in this Section to the
health care plan's contracted health care providers or another
entity. Only a clinical peer may make an adverse determination. However, the
ultimate responsibility for
coverage and payment decisions may not be delegated.
(g) Coverage and payment for post-stabilization medical services for which
prior
authorization or deemed approval is received shall not be retrospectively
denied.
(h) Nothing in this Section shall prohibit the imposition of deductibles,
copayments, and co-insurance.
Nothing in this Section alters the prohibition on billing enrollees contained
in the Health Maintenance Organization Act.
(Source: P.A. 102-901, eff. 7-1-22.)
|
