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215 ILCS 200/15 (215 ILCS 200/15)
Sec. 15. Definitions. As used in this Act:
"Adverse determination" has the meaning given to that term in Section 10 of the Health Carrier External Review Act.
"Appeal" means a formal request, either orally or in writing, to reconsider an adverse determination.
"Approval" means a determination by a health insurance issuer or its contracted utilization review organization that a health care service has been reviewed and, based on the information provided, satisfies the health insurance issuer's or its contracted utilization review organization's requirements for medical necessity and appropriateness.
"Clinical review criteria" has the meaning given to that term in Section 10 of the Health Carrier External Review Act.
"Department" means the Department of Insurance.
"Emergency medical condition" has the meaning given to that term in Section 10 of the Managed Care Reform and Patient Rights Act.
"Emergency services" has the meaning given to that term in federal health insurance reform requirements for the group and individual health insurance markets, 45 CFR 147.138.
"Enrollee" has the meaning given to that term in Section 10 of the Managed Care Reform and Patient Rights Act.
"Health care professional" has the meaning given to that term in Section 10 of the Managed Care Reform and Patient Rights Act.
"Health care provider" has the meaning given to that term in Section 10 of the Managed Care Reform and Patient Rights Act, except that facilities licensed under the Nursing Home Care Act and long-term care facilities as defined in Section 1-113 of the Nursing Home Care Act are excluded from this Act. "Health care service" means any services or level of services included in the furnishing to an individual of medical care or the hospitalization incident to the furnishing of such care, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing, or healing human illness or injury, including behavioral health, mental health, home health, and pharmaceutical services and products.
"Health insurance issuer" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.
"Medically necessary" means a health care professional exercising prudent clinical judgment would provide care to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms and that are: (i) in accordance with generally accepted standards of medical practice; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration and are considered effective for the patient's illness, injury, or disease; and (iii) not primarily for the convenience of the patient, treating physician, other health care professional, caregiver, family member, or other interested party, but focused on what is best for the patient's health outcome.
"Physician" means a person licensed under the Medical Practice Act of 1987 or licensed under the laws of another state to practice medicine in all its branches.
"Prior authorization" means the process by which health insurance issuers or their contracted utilization review organizations determine the medical necessity and medical appropriateness of otherwise covered health care services before the rendering of such health care services. "Prior authorization" includes any health insurance issuer's or its contracted utilization review organization's requirement that an enrollee, health care professional, or health care provider notify the health insurance issuer or its contracted utilization review organization before, at the time of, or concurrent to providing a health care service.
"Urgent health care service" means a health care service with respect to which the application of the time periods for making a non-expedited prior authorization that in the opinion of a health care professional with knowledge of the enrollee's medical condition:
(1) could seriously jeopardize the life or health of | | the enrollee or the ability of the enrollee to regain maximum function; or
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| (2) could subject the enrollee to severe pain that
| | cannot be adequately managed without the care or treatment that is the subject of the utilization review.
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| "Urgent health care service" does not include emergency services.
"Utilization review organization" has the meaning given to that term in 50 Ill. Adm. Code 4520.30.
(Source: P.A. 102-409, eff. 1-1-22.)
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