(215 ILCS 180/1)
Sec. 1. Short title. This Act may be cited as the Health Carrier External Review Act.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/5)
Sec. 5. Purpose and intent. The purpose of this Act is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination, as defined in this Act.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/10) (Text of Section from P.A. 98-756) Sec. 10. Definitions. For the purposes of this Act: "Adverse determination" means: (1) a determination by a health carrier or its | ||
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(2) the denial, reduction, or termination of or | ||
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(3) a rescission of coverage determination, which | ||
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"Authorized representative" means: (1) a person to whom a covered person has given | ||
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(2) a person authorized by law to provide substituted | ||
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(3) a family member of the covered person or the | ||
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(4) a health care provider when the covered person's | ||
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(5) in the case of an urgent care request, a health | ||
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"Best evidence" means evidence based on: (1) randomized clinical trials; (2) if randomized clinical trials are not available, | ||
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(3) if items (1) and (2) are not available, then | ||
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(4) if items (1), (2), and (3) are not available, | ||
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"Case-series" means an evaluation of a series of patients with a particular outcome, without the use of a control group. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. "Cohort study" means a prospective evaluation of 2 groups of patients with only one group of patients receiving specific intervention. "Concurrent review" means a review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional, or other inpatient or outpatient health care setting. "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. "Director" means the Director of the Department of Insurance. "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the individual or, with | ||
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(2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. "Emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition. "Evidence-based standard" means the conscientious, explicit, and judicious use of the current best evidence based on an overall systematic review of the research in making decisions about the care of individual patients. "Expert opinion" means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. "Facility" means an institution providing health care services or a health care setting. "Final adverse determination" means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth by the Managed Care Reform and Patient Rights Act. "Health benefit plan" means a policy, contract, certificate, plan, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. "Health care provider" or "provider" means a physician, hospital facility, or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with State law, responsible for recommending health care services on behalf of a covered person. "Health care services" means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. "Health carrier" means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, or any other entity providing a plan of health insurance, health benefits, or health care services. "Health carrier" also means Limited Health Service Organizations (LHSO) and Voluntary Health Service Plans. "Health information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to: (1) the past, present, or future physical, mental, or | ||
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(2) the provision of health care services to an | ||
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(3) payment for the provision of health care services | ||
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"Independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. "Medical or scientific evidence" means evidence found in the following sources: (1) peer-reviewed scientific studies published in or | ||
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(2) peer-reviewed medical literature, including | ||
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(3) medical journals recognized by the Secretary of | ||
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(4) the following standard reference compendia: (a) The American Hospital Formulary Service-Drug | ||
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(b) Drug Facts and Comparisons; (c) The American Dental Association Accepted | ||
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(d) The United States Pharmacopoeia-Drug | ||
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(5) findings, studies, or research conducted by or | ||
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(a) the federal Agency for Healthcare Research | ||
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(b) the National Institutes of Health; (c) the National Cancer Institute; (d) the National Academy of Sciences; (e) the Centers for Medicare & Medicaid Services; (f) the federal Food and Drug Administration; and (g) any national board recognized by the National | ||
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(6) any other medical or scientific evidence that is | ||
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"Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. "Prospective review" means a review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health carrier's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision. "Protected health information" means health information (i) that identifies an individual who is the subject of the information; or (ii) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual. "Randomized clinical trial" means a controlled prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time. "Retrospective review" means any review of a request for a benefit that is not a concurrent or prospective review request. "Retrospective review" does not include the review of a claim that is limited to veracity of documentation or accuracy of coding. "Utilization review" has the meaning provided by the Managed Care Reform and Patient Rights Act. "Utilization review organization" means a utilization review program as defined in the Managed Care Reform and Patient Rights Act.(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12; 98-756, eff. 7-16-14.) (Text of Section from P.A. 103-650) Sec. 10. Definitions. For the purposes of this Act: "Adverse determination" means: (1) a determination by a health carrier or its | ||
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(2) the denial, reduction, or termination of or | ||
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(3) a rescission of coverage determination, which | ||
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"Authorized representative" means: (1) a person to whom a covered person has given | ||
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(2) a person authorized by law to provide substituted | ||
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(3) a family member of the covered person or the | ||
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(4) a health care provider when the covered person's | ||
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(5) in the case of an urgent care request, a health | ||
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"Best evidence" means evidence based on: (1) randomized clinical trials; (2) if randomized clinical trials are not available, | ||
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(3) if items (1) and (2) are not available, then | ||
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(4) if items (1), (2), and (3) are not available, | ||
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"Case-series" means an evaluation of a series of patients with a particular outcome, without the use of a control group. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. "Clinical review criteria" includes all utilization review criteria as defined in Section 10 of the Managed Care Reform and Patient Rights Act. "Cohort study" means a prospective evaluation of 2 groups of patients with only one group of patients receiving specific intervention. "Concurrent review" means a review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional, or other inpatient or outpatient health care setting. "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. "Director" means the Director of the Department of Insurance. "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the individual or, with | ||
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(2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. "Emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition. "Evidence-based standard" means the conscientious, explicit, and judicious use of the current best evidence based on an overall systematic review of the research in making decisions about the care of individual patients. "Expert opinion" means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. "Facility" means an institution providing health care services or a health care setting. "Final adverse determination" means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth by the Managed Care Reform and Patient Rights Act. "Health benefit plan" means a policy, contract, certificate, plan, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. "Health care provider" or "provider" means a physician, hospital facility, or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with State law, responsible for recommending health care services on behalf of a covered person. "Health care services" means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. "Health carrier" means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, or any other entity providing a plan of health insurance, health benefits, or health care services. "Health carrier" also means Limited Health Service Organizations (LHSO) and Voluntary Health Service Plans. "Health information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to: (1) the past, present, or future physical, mental, or | ||
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(2) the provision of health care services to an | ||
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(3) payment for the provision of health care services | ||
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"Independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. "Medical or scientific evidence" means evidence found in the following sources: (1) peer-reviewed scientific studies published in or | ||
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(2) peer-reviewed medical literature, including | ||
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(3) medical journals recognized by the Secretary of | ||
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(4) the following standard reference compendia: (a) The American Hospital Formulary Service-Drug | ||
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(b) Drug Facts and Comparisons; (c) The American Dental Association Accepted | ||
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(d) The United States Pharmacopoeia-Drug | ||
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(5) findings, studies, or research conducted by or | ||
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(a) the federal Agency for Healthcare Research | ||
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(b) the National Institutes of Health; (c) the National Cancer Institute; (d) the National Academy of Sciences; (e) the Centers for Medicare & Medicaid Services; (f) the federal Food and Drug Administration; and (g) any national board recognized by the National | ||
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(6) any other medical or scientific evidence that is | ||
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"Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. "Prospective review" means a review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health carrier's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision. "Protected health information" means health information (i) that identifies an individual who is the subject of the information; or (ii) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual. "Randomized clinical trial" means a controlled prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time. "Retrospective review" means any review of a request for a benefit that is not a concurrent or prospective review request. "Retrospective review" does not include the review of a claim that is limited to veracity of documentation or accuracy of coding. "Utilization review" has the meaning provided by the Managed Care Reform and Patient Rights Act. "Utilization review organization" means a utilization review program as defined in the Managed Care Reform and Patient Rights Act.(Source: P.A. 103-650, eff. 1-1-25.) (Text of Section from P.A. 103-656) Sec. 10. Definitions. For the purposes of this Act: "Adverse determination" means: (1) a determination by a health carrier or its | ||
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(2) the denial, reduction, or termination of or | ||
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(3) a rescission of coverage determination, which | ||
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"Adverse determination" includes unilateral determinations that replace the requested health care service with an approval of an alternative health care service without the agreement of the covered person or the covered person's attending provider for the requested health care service, or that condition approval of the requested service on first trying an alternative health care service, either if the request was made under a medical exceptions procedure, or if all of the following are true: (1) the requested service was not excluded by name, description, or service category under the written terms of coverage, (2) the alternative health care service poses no greater risk to the patient based on generally accepted standards of care, and (3) the alternative health care service is at least as likely to produce the same or better effect on the covered person's health as the requested service based on generally accepted standards of care. "Adverse determination" includes determinations made based on any source of health information pertaining to the covered person that is used to deny, reduce, replace, condition, or terminate the benefit or payment. "Adverse determination" includes determinations made in response to a request for authorization when the request was submitted by the health care provider regardless of whether the provider gave notice to or obtained the consent of the covered person or authorized representative to file the request. "Adverse determination" does not include substitutions performed under Section 19.5 or 25 of the Pharmacy Practice Act. "Authorized representative" means: (1) a person to whom a covered person has given | ||
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(2) a person authorized by law to provide substituted | ||
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(3) a family member of the covered person or the | ||
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(4) a health care provider when the covered person's | ||
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(5) in the case of an urgent care request, a health | ||
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"Best evidence" means evidence based on: (1) randomized clinical trials; (2) if randomized clinical trials are not available, | ||
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(3) if items (1) and (2) are not available, then | ||
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(4) if items (1), (2), and (3) are not available, | ||
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"Case-series" means an evaluation of a series of patients with a particular outcome, without the use of a control group. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. "Cohort study" means a prospective evaluation of 2 groups of patients with only one group of patients receiving specific intervention. "Concurrent review" means a review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional, or other inpatient or outpatient health care setting. "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. "Director" means the Director of the Department of Insurance. "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the individual or, with | ||
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(2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. "Emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition. "Evidence-based standard" means the conscientious, explicit, and judicious use of the current best evidence based on an overall systematic review of the research in making decisions about the care of individual patients. "Expert opinion" means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. "Facility" means an institution providing health care services or a health care setting. "Final adverse determination" means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth by the Managed Care Reform and Patient Rights Act or as set forth for any additional authorization or internal appeal process provided by contract between the health carrier and the provider. "Final adverse determination" includes determinations made in an appeal of a denial of prior authorization when the appeal was submitted by the health care provider regardless of whether the provider gave notice to or obtained the consent of the covered person or authorized representative to file an internal appeal. "Health benefit plan" means a policy, contract, certificate, plan, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. "Health care provider" or "provider" means a physician, hospital facility, or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with State law, responsible for recommending health care services on behalf of a covered person. "Health care services" means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. "Health carrier" means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, or any other entity providing a plan of health insurance, health benefits, or health care services. "Health carrier" also means Limited Health Service Organizations (LHSO) and Voluntary Health Service Plans. "Health information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to: (1) the past, present, or future physical, mental, or | ||
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(2) the provision of health care services to an | ||
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(3) payment for the provision of health care services | ||
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"Independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. "Medical or scientific evidence" means evidence found in the following sources: (1) peer-reviewed scientific studies published in or | ||
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(2) peer-reviewed medical literature, including | ||
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(3) medical journals recognized by the Secretary of | ||
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(4) the following standard reference compendia: (a) The American Hospital Formulary Service-Drug | ||
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(b) Drug Facts and Comparisons; (c) The American Dental Association Accepted | ||
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(d) The United States Pharmacopoeia-Drug | ||
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(5) findings, studies, or research conducted by or | ||
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(a) the federal Agency for Healthcare Research | ||
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(b) the National Institutes of Health; (c) the National Cancer Institute; (d) the National Academy of Sciences; (e) the Centers for Medicare & Medicaid Services; (f) the federal Food and Drug Administration; and (g) any national board recognized by the National | ||
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(6) any other medical or scientific evidence that is | ||
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"Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. "Prospective review" means a review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health carrier's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision. "Protected health information" means health information (i) that identifies an individual who is the subject of the information; or (ii) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual. "Randomized clinical trial" means a controlled prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time. "Retrospective review" means any review of a request for a benefit that is not a concurrent or prospective review request. "Retrospective review" does not include the review of a claim that is limited to veracity of documentation or accuracy of coding. "Utilization review" has the meaning provided by the Managed Care Reform and Patient Rights Act. "Utilization review organization" means a utilization review program as defined in the Managed Care Reform and Patient Rights Act.(Source: P.A. 103-656, eff. 1-1-25.) |
(215 ILCS 180/15)
Sec. 15. Applicability and scope. (a) Except as provided in subsection (b) of this Section, this Act shall apply to all health carriers. (b) The provisions of this Act shall not apply to a policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance as defined by Article XIXA of the Illinois Insurance Code, vision care, or any other limited supplemental benefit; a Medicare supplement policy of insurance as defined by the Director by regulation; coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program; any coverage issued under Chapter 55 of Title 10, U.S. Code and any coverage issued as supplement to that coverage; any coverage issued as supplemental to liability insurance, workers' compensation, or similar insurance; automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/20)
Sec. 20. Notice of right to external review. (a) At the same time the health carrier sends written notice of a covered person's right to appeal a coverage decision upon an adverse determination or a final adverse determination, a health carrier shall notify a covered person, the covered person's authorized representative, if any, and a covered person's health care provider in writing of the covered person's right to request an external review as provided by this Act. The written notice required shall include the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You have the right to have our decision reviewed by an independent review organization not associated with us by submitting a written request for an external review to the Department of Insurance, Office of Consumer Health Information, 320 West Washington Street, 4th Floor, Springfield, Illinois, 62767.". The written notice shall include a copy of the Department's Request for External Review form. (a-5) The Department may prescribe the form and content of the notice required under this Section. (b) In addition to the notice required in subsection (a), for a notice related to an adverse determination, the health carrier shall include a statement informing the covered person of all of the following: (1) If the covered person has a medical condition | ||
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(2) The covered person or the covered person's | ||
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(3) If the covered person or the covered person's | ||
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(4) If an adverse determination concerns a denial of | ||
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(c) In addition to the notice required in subsection (a), for a notice related to a final adverse determination, the health carrier shall include a statement informing the covered person of all of the following: (1) if the covered person has a medical condition | ||
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(2) if a final adverse determination concerns an | ||
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(3) if a final adverse determination concerns a | ||
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(d) In addition to the information to be provided pursuant to subsections (a), (b), and (c) of this Section, the health carrier shall include a copy of the description of both the required standard and expedited external review procedures. The description shall highlight the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information, including any forms used to process an external review.
(e) As part of any forms provided under subsection (d) of this Section, the health carrier shall include an authorization form, or other document approved by the Director, by which the covered person, for purposes of conducting an external review under this Act, authorizes the health carrier and the covered person's treating health care provider to disclose protected health information, including medical records, concerning the covered person that is pertinent to the external review, as provided in the Illinois Insurance Code. (Source: P.A. 99-480, eff. 9-9-15.) |
(215 ILCS 180/25)
Sec. 25. Request for external review. A covered person or the covered person's authorized representative may make a request for a standard external or expedited external review of an adverse determination or final adverse determination. Except as set forth in Sections 40 and 42 of this Act, all requests for external review shall be made in writing to the Director. Health carriers must provide covered persons with forms to request external reviews.
(Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.) |
(215 ILCS 180/30)
Sec. 30. Exhaustion of internal appeal process. (a) Except as provided in subsection (b) of this Section, a request for an external review shall not be made until the covered person has exhausted the health carrier's internal appeal process. (b) A covered person shall be considered to have exhausted the health carrier's internal appeal process for purposes of this Section if: (1) the covered person or the covered person's | ||
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(2) the covered person or the covered person's | ||
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(3) the health carrier agrees to waive the exhaustion | ||
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(4) the covered person has a medical condition in | ||
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(5) an adverse determination concerns a denial of | ||
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(6) the health carrier has failed to comply with | ||
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(Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.) |
(215 ILCS 180/35) Sec. 35. Standard external review. (a) Within 4 months after the date of receipt of a notice of an adverse determination or final adverse determination, a covered person or the covered person's authorized representative may file a request for an external review with the Director. Within one business day after the date of receipt of a request for external review, the Director shall send a copy of the request to the health carrier. (b) Within 5 business days following the date of receipt of the external review request, the health carrier shall complete a preliminary review of the request to determine whether:
(1) the individual is or was a covered person in the | ||
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(2) the health care service that is the subject of | ||
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(3) the covered person has exhausted the health | ||
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(4) (blank); and (5) the covered person has provided all the | ||
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(c) Within one business day after completion of the preliminary review, the health carrier shall notify the Director and covered person and, if applicable, the covered person's authorized representative in writing whether the request is complete and eligible for external review. If the request: (1) is not complete, the health carrier shall inform | ||
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(2) is not eligible for external review, the health | ||
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The Department may specify the form for the health carrier's notice of initial determination under this subsection (c) and any supporting information to be included in the notice. The notice of initial determination of ineligibility shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the Director by filing a complaint with the Director. Notwithstanding a health carrier's initial determination that the request is ineligible for external review, the Director may determine that a request is eligible for external review and require that it be referred for external review. In making such determination, the Director's decision shall be in accordance with the terms of the covered person's health benefit plan, unless such terms are inconsistent with applicable law, and shall be subject to all applicable provisions of this Act. (d) Whenever the Director receives notice that a request is eligible for external review following the preliminary review conducted pursuant to this Section, within one business day after the date of receipt of the notice, the Director shall: (1) assign an independent review organization from | ||
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(2) notify in writing the covered person and, if | ||
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The Director shall include in the notice provided to the covered person and, if applicable, the covered person's authorized representative a statement that the covered person or the covered person's authorized representative may, within 5 business days following the date of receipt of the notice provided pursuant to item (2) of this subsection (d), submit in writing to the assigned independent review organization additional information that the independent review organization shall consider when conducting the external review. The independent review organization is not required to, but may, accept and consider additional information submitted after 5 business days. (e) The assignment by the Director of an approved independent review organization to conduct an external review in accordance with this Section shall be done on a random basis among those independent review organizations approved by the Director pursuant to this Act. (f) Within 5 business days after the date of receipt of the notice provided pursuant to item (1) of subsection (d) of this Section, the health carrier or its designee utilization review organization shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination; in such cases, the following provisions shall apply: (1) Except as provided in item (2) of this subsection | ||
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(2) If the health carrier or its utilization review | ||
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(3) Within one business day after making the decision | ||
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(g) Upon receipt of the information from the health carrier or its utilization review organization, the assigned independent review organization shall review all of the information and documents and any other information submitted in writing to the independent review organization by the covered person and the covered person's authorized representative. (h) Upon receipt of any information submitted by the covered person or the covered person's authorized representative, the independent review organization shall forward the information to the health carrier within 1 business day. (1) Upon receipt of the information, if any, the | ||
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(2) Reconsideration by the health carrier of its | ||
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(3) The external review may only be terminated if the | ||
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(A) Within one business day after making the | ||
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(B) Upon notice from the health carrier that the | ||
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(i) In addition to the documents and information provided by the health carrier or its utilization review organization and the covered person and the covered person's authorized representative, if any, the independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision: (1) the covered person's pertinent medical records; (2) the covered person's health care provider's | ||
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(3) consulting reports from appropriate health care | ||
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(4) the terms of coverage under the covered person's | ||
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(5) the most appropriate practice guidelines, which | ||
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(6) any applicable clinical review criteria developed | ||
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(7) the opinion of the independent review | ||
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(8) (blank); and (9) in the case of medically necessary determinations | ||
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(i-5) For an adverse determination or final adverse determination involving mental, emotional, nervous, or substance use disorders or conditions, the independent review organization shall: (1) consider the documents and information as set | ||
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(2) make its decision, pursuant to subsection (j), | ||
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(j) Within 5 days after the date of receipt of all necessary information, but in no event more than 45 days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the Director, the health carrier, the covered person, and, if applicable, the covered person's authorized representative. In reaching a decision, the assigned independent review organization is not bound by any claim determinations reached prior to the submission of information to the independent review organization. In such cases, the following provisions shall apply: (1) The independent review organization shall include | ||
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(A) a general description of the reason for the | ||
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(B) the date the independent review organization | ||
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(C) the time period during which the external | ||
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(D) references to the evidence or documentation, | ||
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(E) the date of its decision; (F) the principal reason or reasons for its | ||
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(G) the rationale for its decision. (2) (Blank). (3) (Blank). (4) Upon receipt of a notice of a decision reversing | ||
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(Source: P.A. 102-579, eff. 1-1-22.) |
(215 ILCS 180/40) Sec. 40. Expedited external review. (a) A covered person or a covered person's authorized representative may file a request for an expedited external review with the Director either orally or in writing: (1) immediately after the date of receipt of a notice | ||
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(2) immediately after the date of receipt of a notice | ||
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(3) if a health carrier fails to provide a decision | ||
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(b) Upon receipt of a request for an expedited external review, the Director shall immediately send a copy of the request to the health carrier. Immediately upon receipt of the request for an expedited external review, the health carrier shall determine whether the request meets the reviewability requirements set forth in subsection (b) of Section 35. In such cases, the following provisions shall apply: (1) The health carrier shall immediately notify the | ||
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(2) The notice of initial determination shall | ||
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(3) The Director may determine that a request is | ||
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(4) In making a determination under item (3) of this | ||
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(5) The Director may specify the form for the health | ||
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(c) Upon receipt of the notice that the request meets the reviewability requirements, the Director shall immediately assign an independent review organization from the list of approved independent review organizations compiled and maintained by the Director to conduct the expedited review. In such cases, the following provisions shall apply: (1) The assignment of an approved independent review | ||
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(2) The Director shall immediately notify the health | ||
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(3) If the health carrier or its utilization review | ||
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(4) Within one business day after making the decision | ||
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(d) In addition to the documents and information provided by the health carrier or its utilization review organization and any documents and information provided by the covered person and the covered person's authorized representative, the independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider information as required by subsection (i) of Section 35 of this Act in reaching a decision. (d-5) For expedited external reviews involving mental, emotional, nervous, or substance use disorders or conditions, the independent review organization shall consider documents and information and shall make a decision to uphold or reverse the adverse determination or final adverse determination pursuant to subsection (i-5) of Section 35. (e) As expeditiously as the covered person's medical condition or circumstances requires, but in no event more than 72 hours after the date of receipt of the request for an expedited external review, the assigned independent review organization shall: (1) make a decision to uphold or reverse the final | ||
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(2) notify the Director, the health carrier, the | ||
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(f) In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier's utilization review process or the health carrier's internal appeal process.
(g) Upon receipt of notice of a decision reversing the adverse determination or final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination. (h) If the notice provided pursuant to subsection (e) of this Section was not in writing, then within 48 hours after the date of providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the Director, the health carrier, the covered person, and, if applicable, the covered person's authorized representative including the information set forth in subsection (j) of Section 35 of this Act as applicable. (i) An expedited external review may not be provided for retrospective adverse or final adverse determinations.
(j) The assignment by the Director of an approved independent review organization to conduct an external review in accordance with this Section shall be done on a random basis among those independent review organizations approved by the Director pursuant to this Act. (Source: P.A. 102-579, eff. 1-1-22.) |
(215 ILCS 180/42) Sec. 42. External review of experimental or investigational treatment adverse determinations. (a) Within 4 months after the date of receipt of a notice of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or the covered person's authorized representative may file a request for an external review with the Director. (b) The following provisions apply to cases concerning expedited external reviews: (1) A covered person or the covered person's | ||
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(2) Upon receipt of a request for an expedited | ||
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(3) The following provisions apply concerning notice: (A) Upon notice of the request for an expedited | ||
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(B) The Director may specify the form for the | ||
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(C) The notice of initial determination under | ||
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(4) The following provisions apply concerning the | ||
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(A) The Director may determine that a request is | ||
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(B) In making a determination under subdivision | ||
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(5) Upon receipt of the notice that the expedited | ||
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(6) At the time the health carrier receives the | ||
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(c) Except for a request for an expedited external review made pursuant to subsection (b) of this Section, within one business day after the date of receipt of a request for external review, the Director shall send a copy of the request to the health carrier. (d) Within 5 business days following the date of receipt of the external review request, the health carrier shall complete a preliminary review of the request to determine whether: (1) the individual is or was a covered person in the | ||
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(2) the recommended or requested health care service | ||
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(3) the covered person's health care provider has | ||
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(A) standard health care services or treatments | ||
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(B) standard health care services or treatments | ||
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(C) there is no available standard health care | ||
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(4) the covered person's health care provider: (A) has recommended a health care service or | ||
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(B) who is a licensed, board certified or board | ||
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(5) the covered person has exhausted the health | ||
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(6) the covered person has provided all the | ||
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(e) The following provisions apply concerning requests: (1) Within one business day after completion of the | ||
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(2) If the request: (A) is not complete, then the health carrier | ||
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(B) is not eligible for external review, then the | ||
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(3) The Department may specify the form for the | ||
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(4) The notice of initial determination of | ||
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(5) Notwithstanding a health carrier's initial | ||
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(f) Whenever a request for external review is determined eligible for external review, the health carrier shall notify the Director and the covered person and, if applicable, the covered person's authorized representative. (g) Whenever the Director receives notice that a request is eligible for external review following the preliminary review conducted pursuant to this Section, within one business day after the date of receipt of the notice, the Director shall: (1) assign an independent review organization from | ||
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(2) notify in writing the covered person and, if | ||
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The Director shall include in the notice provided to the covered person and, if applicable, the covered person's authorized representative a statement that the covered person or the covered person's authorized representative may, within 5 business days following the date of receipt of the notice provided pursuant to item (2) of this subsection (g), submit in writing to the assigned independent review organization additional information that the independent review organization shall consider when conducting the external review. The independent review organization is not required to, but may, accept and consider additional information submitted after 5 business days. (h) The following provisions apply concerning assignments and clinical reviews: (1) Within one business day after the receipt of the | ||
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(2) The provisions of this item (2) apply concerning | ||
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(A) In selecting clinical reviewers pursuant to | ||
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(B) Neither the covered person, the covered | ||
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(3) In accordance with subsection (l) of this | ||
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(4) In reaching an opinion, clinical reviewers are | ||
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(i) Within 5 business days after the date of receipt of the notice provided pursuant to subsection (g) of this Section, the health carrier or its designee utilization review organization shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination; in such cases, the following provisions shall apply: (1) Except as provided in item (2) of this subsection | ||
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(2) If the health carrier or its utilization review | ||
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(3) Immediately upon making the decision to terminate | ||
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(j) Upon receipt of the information from the health carrier or its utilization review organization, each clinical reviewer selected pursuant to subsection (h) of this Section shall review all of the information and documents and any other information submitted in writing to the independent review organization by the covered person and the covered person's authorized representative. (k) Upon receipt of any information submitted by the covered person or the covered person's authorized representative, the independent review organization shall forward the information to the health carrier within one business day. In such cases, the following provisions shall apply: (1) Upon receipt of the information, if any, the | ||
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(2) Reconsideration by the health carrier of its | ||
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(3) The external review may be terminated only if the | ||
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(A) Immediately upon making its decision to | ||
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(B) Upon notice from the health carrier that the | ||
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(l) The following provisions apply concerning clinical review opinions: (1) Except as provided in item (3) of this subsection | ||
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(2) Except for an opinion provided pursuant to item | ||
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(A) a description of the covered person's medical | ||
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(B) a description of the indicators relevant to | ||
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(C) a description and analysis of any medical or | ||
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(D) a description and analysis of any | ||
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(E) information on whether the reviewer's | ||
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(3) The provisions of this item (3) apply concerning | ||
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(A) For an expedited external review, each | ||
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(B) If the opinion provided pursuant to | ||
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(m) In addition to the documents and information provided by the health carrier or its utilization review organization and the covered person and the covered person's authorized representative, if any, each clinical reviewer selected pursuant to subsection (h) of this Section, to the extent the information or documents are available and the clinical reviewer considers appropriate, shall consider the following in reaching a decision: (1) the covered person's pertinent medical records; (2) the covered person's health care provider's | ||
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(3) consulting reports from appropriate health care | ||
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(4) the terms of coverage under the covered person's | ||
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(5) whether (A) the recommended or requested health | ||
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(n) The following provisions apply concerning decisions, notices, and recommendations: (1) The provisions of this item (1) apply concerning | ||
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(A) Except as provided in subdivision (B) of this | ||
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(B) For an expedited external review, within 48 | ||
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(2) The provisions of this item (2) apply concerning | ||
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(A) If a majority of the clinical reviewers | ||
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(B) If a majority of the clinical reviewers | ||
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(C) The provisions of this subdivision (C) apply | ||
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(i) If the clinical reviewers are evenly | ||
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(ii) The additional clinical reviewer | ||
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(iii) The selection of the additional | ||
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(o) The independent review organization shall include in the notice provided pursuant to subsection (n) of this Section: (1) a general description of the reason for the | ||
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(2) the written opinion of each clinical reviewer, | ||
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(3) the date the independent review organization | ||
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(4) the time period during which the external review | ||
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(5) the date of its decision; (6) the principal reason or reasons for its decision; | ||
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(7) the rationale for its decision. (p) Upon receipt of a notice of a decision reversing the adverse determination or final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination. (q) The assignment by the Director of an approved independent review organization to conduct an external review in accordance with this Section shall be done on a random basis among those independent review organizations approved by the Director pursuant to this Act.
(Source: P.A. 97-574, eff. 8-26-11.) |
(215 ILCS 180/45)
Sec. 45. Binding nature of external review decision. An external review decision is binding on the health carrier. An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or State law. A covered person or the covered person's authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to this Act.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/50)
Sec. 50. Approval of independent review organizations. (a) The Director shall approve independent review organizations eligible to be assigned to conduct external reviews under this Act. (b) In order to be eligible for approval by the Director under this Section to conduct external reviews under this Act an independent review organization:
(1) except as otherwise provided in this Section, | ||
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(2) shall submit an application for approval in | ||
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(c) The Director shall develop an application form for initially approving and for reapproving independent review organizations to conduct external reviews. (d) Any independent review organization wishing to be approved to conduct external reviews under this Act shall submit the application form and include with the form all documentation and information necessary for the Director to determine if the independent review organization satisfies the minimum qualifications established under this Act.
The Director may: (1) approve independent review organizations that are | ||
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(2) by rule establish an application fee that | ||
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(e) An approval is effective for 2 years, unless the Director determines before its expiration that the independent review organization is not satisfying the minimum qualifications established under this Act. (f) Whenever the Director determines that an independent review organization has lost its accreditation or no longer satisfies the minimum requirements established under this Act, the Director shall terminate the approval of the independent review organization and remove the independent review organization from the list of independent review organizations approved to conduct external reviews under this Act that is maintained by the Director. (g) The Director shall maintain and periodically update a list of approved independent review organizations. (h) The Director may promulgate regulations to carry out the provisions of this Section.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/55)
Sec. 55. Minimum qualifications for independent review organizations.
(a) To be approved to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in this Act that include, at a minimum: (1) a quality assurance mechanism that ensures that: (A) external reviews are conducted within the | ||
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(B) selection of qualified and impartial clinical | ||
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(C) for adverse determinations involving | ||
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(D) the health carrier, the covered person, and | ||
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(E) confidentiality of medical and treatment | ||
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(F) any person employed by or under contract with | ||
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(2) a toll-free telephone service operating on a | ||
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(3) an agreement to maintain and provide to the | ||
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(b) All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who meet the following minimum qualifications:
(1) be an expert in the treatment of the covered | ||
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(2) be knowledgeable about the recommended health | ||
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(3) hold a non-restricted license in a state of the | ||
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(4) have no history of disciplinary actions or | ||
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(c) In addition to the requirements set forth in subsection (a), an independent review organization may not own or control, be a subsidiary of, or in any way be owned, or controlled by, or exercise control with a health benefit plan, a national, State, or local trade association of health benefit plans, or a national, State, or local trade association of health care providers. (d) Conflicts of interest prohibited.
In addition to the requirements set forth in subsections (a), (b), and (c) of this Section, to be approved pursuant to this Act to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical reviewer assigned by the independent organization to conduct the external review may have a material professional, familial or financial conflict of interest with any of the following: (1) the health carrier that is the subject of the | ||
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(2) the covered person whose treatment is the subject | ||
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(3) any officer, director or management employee of | ||
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(4) the health care provider, the health care | ||
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(5) the facility at which the recommended health care | ||
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(6) the developer or manufacturer of the principal | ||
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(e) An independent review organization that is accredited by a nationally recognized private accrediting entity that has independent review accreditation standards that the Director has determined are equivalent to or exceed the minimum qualifications of this Section shall be presumed to be in compliance with this Section and shall be eligible for approval under this Act. (f) An independent review organization shall be unbiased. An independent review organization shall establish and maintain written procedures to ensure that it is unbiased in addition to any other procedures required under this Section. (g) Nothing in this Act precludes or shall be interpreted to preclude a health carrier from contracting with approved independent review organizations to conduct external reviews.
(Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.) |
(215 ILCS 180/60)
Sec. 60. Hold harmless for independent review organizations. No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent or contractor of an independent review organization shall be liable for damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization's or person's duties under the law during or upon completion of an external review conducted pursuant to this Act, unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/65) Sec. 65. External review reporting requirements. (a) Each health carrier shall maintain written records in the aggregate, by state, and for each type of health benefit plan offered by the health carrier on all requests for external review that the health carrier received notice from the Director for each calendar year and submit a report to the Director in the format specified by the Director by June 1 of each year. (a-5) An independent review organization assigned pursuant to this Act to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and submit a report in the format specified by the Director by March 1 of each year. (a-10) The report required by subsection (a-5) shall include in the aggregate by state, and for each health carrier: (1) the total number of requests for external review; (2) the number of requests for external review | ||
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(3) the average length of time for resolution; (4) a summary of the types of coverages or cases for | ||
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(5) the number of external reviews that were | ||
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(6) any other information the Director may request or | ||
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(a-15) The independent review organization shall retain the written records required pursuant to this Section for at least 3 years. (b) The report required under subsection (a) of this Section shall include in the aggregate, by state, and by type of health benefit plan:
(1) the total number of requests for external review; (2) the total number of requests for expedited | ||
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(3) the total number of requests for external review | ||
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(4) the number of requests for external review | ||
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(A) the number of requests for external review | ||
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(B) the number of requests for external review | ||
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(C) the number of requests for expedited external | ||
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(D) the number of requests for expedited external | ||
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(5) the average length of time for resolution for an | ||
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(6) the average length of time for resolution for an | ||
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(7) a summary of the types of coverages or cases for | ||
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(A) denial of care or treatment (dissatisfaction | ||
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(B) denial of diagnostic procedure | ||
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(C) denial of referral request (dissatisfaction | ||
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(D) claims and utilization review | ||
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(8) the number of external reviews that were | ||
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(9) any other information the Director may request or | ||
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(Source: P.A. 99-537, eff. 1-1-17.) |
(215 ILCS 180/70)
Sec. 70. Funding of external review. The health carrier shall be solely responsible for paying the cost of external reviews conducted by independent review organizations.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/75)
Sec. 75. Disclosure requirements. (a) Each health carrier shall include a description of the external review procedures in, or attached to, the policy, certificate, membership booklet, and outline of coverage or other evidence of coverage it provides to covered persons. (b) The description required under subsection (a) of this Section shall include a statement that informs the covered person of the right of the covered person to file a request for an external review of an adverse determination or final adverse determination with the Director. The statement shall explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness. The statement shall include the toll-free telephone number and address of the Office of Consumer Health Insurance within the Department of Insurance.
(Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.) |
(215 ILCS 180/80) Sec. 80. Administration and enforcement. (a) The Director of Insurance may adopt rules necessary to implement the Department's responsibilities under this Act. (b) The Director is authorized to make use of any of the powers established under the Illinois Insurance Code to enforce the laws of this State. This includes but is not limited to, the Director's administrative authority to investigate, issue subpoenas, conduct depositions and hearings, issue orders, including, without limitation, orders pursuant to Article XII 1/2 and Section 401.1 of the Illinois Insurance Code, and impose penalties.
(Source: P.A. 97-574, eff. 8-26-11.) |
(215 ILCS 180/90)
Sec. 90. (Amendatory provisions; text omitted).
(Source: P.A. 96-857, eff. 7-1-10; text omitted.) |
(215 ILCS 180/95)
Sec. 95. (Amendatory provisions; text omitted).
(Source: P.A. 96-857, eff. 7-1-10; text omitted.) |
(215 ILCS 180/96)
Sec. 96. No acceleration or delay. Where this Act makes changes in a statute that is represented in this Act by text that is not yet or no longer in effect (for example, a Section represented by multiple versions), the use of that text does not accelerate or delay the taking effect of (i) the changes made by this Act or (ii) provisions derived from any other Public Act.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/97)
Sec. 97. Severability. The provisions of this Act are severable under Section 1.31 of the Statute on Statutes.
(Source: P.A. 96-857, eff. 7-1-10.) |
(215 ILCS 180/99)
Sec. 99. Effective date. This Act takes effect January 1, 2010, except that the changes to Section 155.36 of the Illinois Insurance Code and Sections 40 and 45 of the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act take effect July 1, 2010.
(Source: P.A. 96-857, eff. 1-5-10.) |