[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
| [ Engrossed ] | [ House Amendment 001 ] | [ House Amendment 002 ] |
| [ House Amendment 003 ] | [ House Amendment 005 ] |
90_HB0626
215 ILCS 125/2-1.1 new
215 ILCS 125/2-1.2 new
215 ILCS 125/2-1.3 new
215 ILCS 125/2-1.4 new
215 ILCS 125/2-1.5 new
215 ILCS 125/2-1.6 new
215 ILCS 125/2-1.7 new
215 ILCS 125/Art. VII heading new
215 ILCS 125/7-1 new
215 ILCS 125/7-5 new
215 ILCS 125/7-10 new
215 ILCS 125/7-15 new
215 ILCS 125/7-20 new
215 ILCS 125/7-25 new
215 ILCS 125/7-30 new
215 ILCS 125/7-35 new
215 ILCS 125/7-40 new
215 ILCS 125/4-6 rep.
Amends the Health Maintenance Organization Act.
Establishes requirements for disclosure of information to
subscribers and enrollees. Sets forth standards for the
handling of grievances by enrollees. Specifies procedures
and timelines. Establishes the procedures for terminating
health care professionals. Prohibits an organization from
restricting information that a health care provider may give
to a patient. Requires that an adequate network of providers
be maintained. Creates the Utilization Review Law. Sets
forth standards and procedures for determining whether
services are covered. Establishes timeframes for making
utilization review determinations. Sets forth requirements
for appeals from adverse decisions.
LRB9000248JSmb
LRB9000248JSmb
1 AN ACT relating to the delivery of health care services.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Health Maintenance Organization Act is
5 amended by adding Sections 2-1.1, 2-1.2, 2-1.3, 2-1.4, 2-1.5,
6 2-1.6, and 2-1.7 and Article VII as follows:
7 (215 ILCS 125/2-1.1 new)
8 Sec. 2-1.1. Disclosure of information.
9 (a) Each subscriber, and upon request each prospective
10 subscriber prior to enrollment, shall be supplied with
11 written disclosure information which may be incorporated into
12 the member handbook or the subscriber contract or
13 certificate containing at least the information specified
14 in this Section. In the event of any inconsistency between
15 any separate written disclosure statement and the
16 subscriber contract or certificate, the terms of the
17 subscriber contract or certificate shall be controlling.
18 The information to be disclosed shall include, at a
19 minimum, all of the following:
20 (1) A description of coverage provisions, health
21 care benefits, benefit maximums, including benefit
22 limitations, and exclusions of coverage, including the
23 definition of medical necessity used in determining
24 whether benefits will be covered.
25 (2) A description of all prior authorization or
26 other requirements for treatments and services.
27 (3) A description of utilization review policies
28 and procedures used by the health maintenance
29 organization including the circumstances under which
30 utilization review will be undertaken, the toll-free
31 telephone number of the utilization review agent, the
-2- LRB9000248JSmb
1 timeframes under which utilization review decisions must
2 be made for prospective, retrospective, and concurrent
3 decisions, the right to reconsideration, the right to an
4 appeal, including the expedited and standard appeals
5 processes and the timeframes for those appeals, the
6 right to designate a representative, a notice that all
7 denials of claims will be made by qualified clinical
8 personnel and that all notices of denials will include
9 information about the basis of the decision, and further
10 appeal rights, if any.
11 (4) A description prepared annually of the types of
12 methodologies the health maintenance organization uses to
13 reimburse providers specifying the type of
14 methodology that is used to reimburse particular types of
15 providers or reimburse for the provision of
16 particular types of services; provided, however,
17 that nothing in this item should be construed to require
18 disclosure of individual contracts or the specific
19 details of any financial arrangement between a health
20 maintenance organization and a health care provider.
21 (5) An explanation of a subscriber's financial
22 responsibility for payment of premiums, coinsurance,
23 co-payments, deductibles, and any other charges, annual
24 limits on a subscriber's financial responsibility, caps
25 on payments for covered services and financial
26 responsibility for non-covered health care procedures,
27 treatments, or services provided within the health
28 maintenance organization.
29 (6) An explanation of a subscriber's financial
30 responsibility for payment when services are provided by
31 a health care provider who is not part of the health
32 maintenance organization or by any provider without
33 required authorization or when a procedure, treatment, or
34 service is not a covered health care benefit.
-3- LRB9000248JSmb
1 (7) A description of the grievance procedures to
2 be used to resolve disputes between a health maintenance
3 organization and an enrollee, including the right to
4 file a grievance regarding any dispute between an
5 enrollee and a health maintenance organization, the right
6 to file a grievance orally when the dispute is about
7 referrals or covered benefits, the toll-free telephone
8 number that enrollees may use to file an oral grievance,
9 the timeframes and circumstances for expedited and
10 standard grievances, the right to appeal a grievance
11 determination and the procedures for filing the appeal,
12 the timeframes and circumstances for expedited and
13 standard appeals, the right to designate a
14 representative, a notice that all disputes involving
15 clinical decisions will be made by qualified clinical
16 personnel, and that all notices of determination will
17 include information about the basis of the decision
18 and further appeal rights, if any.
19 (8) A description of the procedure for providing
20 care and coverage 24 hours a day for emergency services.
21 The description shall include a definition of
22 emergency services, notice that emergency services are
23 not subject to prior approval, and an explanation of
24 the enrollee's financial and other responsibilities
25 regarding obtaining those services including when
26 those services are received outside the health
27 maintenance organization's service area.
28 (9) A description of procedures for enrollees to
29 select and access the health maintenance organization's
30 primary and specialty care providers, including notice
31 of how to determine whether a participating provider is
32 accepting new patients.
33 (10) A description of the procedures for changing
34 primary and specialty care providers within the health
-4- LRB9000248JSmb
1 maintenance organization.
2 (11) Notice that an enrollee may obtain a referral
3 to a health care provider outside of the health
4 maintenance organization's network or panel when the
5 health maintenance organization does not have a health
6 care provider with appropriate training and experience in
7 the network or panel to meet the particular health care
8 needs of the enrollee and the procedure by which the
9 enrollee can obtain the referral.
10 (12) Notice that an enrollee with a condition
11 that requires ongoing care from a specialist may
12 request a standing referral to the specialist and
13 the procedure for requesting and obtaining a standing
14 referral.
15 (13) Notice that an enrollee with (i) a
16 life-threatening condition or disease or (ii) a
17 degenerative and disabling condition or disease either of
18 which requires specialized medical care over a prolonged
19 period of time may request a specialist responsible for
20 providing or coordinating the enrollee's medical care and
21 the procedure for requesting and obtaining the
22 specialist.
23 (14) Notice that an enrollee with a (i) a
24 life-threatening condition or disease or (ii) a
25 degenerative and disabling condition or disease either of
26 which requires specialized medical care over a prolonged
27 period of time may request access to a specialty care
28 center and the procedure by which access may be
29 obtained.
30 (15) A description of the mechanisms by which
31 enrollees may participate in the development of the
32 policies of the health maintenance organization.
33 (16) A description of how the health maintenance
34 organization addresses the needs of non-english speaking
-5- LRB9000248JSmb
1 enrollees.
2 (17) Notice of all appropriate mailing addresses
3 and telephone numbers to be utilized by enrollees
4 seeking information or authorization.
5 (18) A listing by specialty, which may be in a
6 separate document that is updated annually, of the name,
7 address, and telephone number of all participating
8 providers, including facilities, and, in addition, in the
9 case of physicians, board certification.
10 (b) Upon request of an enrollee or prospective enrollee,
11 each health maintenance organization shall do all of the
12 following:
13 (1) Provide a list of the names, business
14 addresses, and official positions of the membership of
15 the board of directors, officers, controlling persons,
16 owners, or partners of the health maintenance
17 organization.
18 (2) Provide a copy of the most recent annual
19 certified financial statement of the health maintenance
20 organization, including a balance sheet and summary
21 of receipts and disbursements prepared by a certified
22 public accountant.
23 (3) Provide a copy of the most recent individual,
24 direct pay subscriber contracts.
25 (4) Provide information relating to consumer
26 complaints compiled in the manner set forth in Section
27 143d of the Illinois Insurance Code.
28 (5) Provide the procedures for protecting the
29 confidentiality of medical records and other enrollee
30 information.
31 (6) Allow enrollees and prospective enrollees to
32 inspect drug formularies used by the health
33 maintenance organization and disclose whether individual
34 drugs are included or excluded from coverage to an
-6- LRB9000248JSmb
1 enrollee or prospective enrollee who requests this
2 information.
3 (7) Provide a written description of the
4 organizational arrangements and ongoing procedures of
5 the health maintenance organization's quality assurance
6 program.
7 (8) Provide a description of the procedures
8 followed by the health maintenance organization in
9 making decisions about the experimental or
10 investigational nature of individual drugs, medical
11 devices, or treatments in clinical trials.
12 (9) Provide individual health practitioner
13 affiliations with participating hospitals, if any.
14 (10) Upon written request, provide specific
15 written clinical review criteria relating to a
16 particular condition or disease and, where appropriate,
17 other clinical information that the organization might
18 consider in its utilization review; the organization
19 may include with the information a description of how it
20 will be used in the utilization review process,
21 however, to the extent the information is proprietary to
22 the organization, the enrollee or prospective enrollee
23 shall only use the information for the purposes of
24 assisting the enrollee or prospective enrollee in
25 evaluating the covered services provided by the
26 organization.
27 (11) Provide the written application procedures and
28 minimum qualification requirements for health care
29 providers to be considered by the health maintenance
30 organization.
31 (12) Disclose other information as required by
32 the Director.
33 (c) Nothing in this Section shall prevent a health
34 maintenance organization from changing or updating the
-7- LRB9000248JSmb
1 materials that are made available to enrollees.
2 (d) If a primary care provider ceases participation in
3 the health maintenance organization, the organization
4 shall provide written notice within 15 days from the date
5 that the organization becomes aware of the change in status
6 to each of the enrollees who have chosen the provider as
7 their primary care provider. If an enrollee is in an
8 ongoing course of treatment with any other participating
9 provider who becomes unavailable to continue to provide
10 services to the enrollee and the health maintenance
11 organization is aware of the ongoing course of treatment,
12 the health maintenance organization shall provide
13 written notice within 15 days from the date that the
14 health maintenance organization becomes aware of the
15 unavailability to the enrollee. Each notice shall also
16 describe the procedures for continuing care.
17 (e) A health maintenance organization shall annually on
18 or before April 1, file a report with the Director showing
19 its financial condition as of the last day of the preceding
20 calendar year, in such form and providing such information
21 as the Director shall prescribe.
22 (f) A health maintenance organization offering to
23 indemnify enrollees for non-participating provider services
24 shall on a quarterly basis file a report with the Director
25 showing the percentage utilization for the preceding
26 quarter of non-participating provider services in such form
27 and providing such other information as the Director
28 shall prescribe.
29 (215 ILCS 125/2-1.2 new)
30 Sec. 2-1.2. Grievance procedure.
31 (a) A health maintenance organization shall establish
32 and maintain a grievance procedure. Pursuant to such
33 procedure, enrollees shall be entitled to seek a review of
-8- LRB9000248JSmb
1 determinations by the organization other than
2 determinations subject to the provisions of Article VII.
3 (b) An organization shall provide to all enrollees
4 written notice of the grievance procedure in the member
5 handbook and at any time that the organization denies
6 access to a referral or determines that a requested
7 benefit is not covered pursuant to the terms of the
8 contract. In the event that an organization denies a service
9 as an adverse determination as defined in Article VII, the
10 organization shall inform the enrollee or the enrollee's
11 designee of the appeal rights provided for in Article VII.
12 The notice to an enrollee describing the grievance
13 process shall explain the process for filing a grievance
14 with the organization, the timeframes within which a
15 grievance determination must be made, and the right of an
16 enrollee to designate a representative to file a grievance on
17 behalf of the enrollee.
18 The organization shall assure that the grievance
19 procedure is reasonably accessible to those who do not speak
20 English.
21 (c) The organization may require an enrollee to file a
22 grievance in writing, by letter or by a grievance form which
23 shall be made available by the organization, however, an
24 enrollee may submit an oral grievance in connection with (i)
25 a denial of, or failure to pay for, a referral or (ii) a
26 determination as to whether a benefit is covered pursuant to
27 the terms of the enrollee's contract. In connection with
28 the submission of an oral grievance, an organization may
29 require that the enrollee sign a written acknowledgment of
30 the grievance prepared by the organization summarizing the
31 nature of the grievance. The acknowledgment shall be
32 mailed promptly to the enrollee, who shall sign and return
33 the acknowledgment, with any amendments, in order to
34 initiate the grievance. The grievance acknowledgment shall
-9- LRB9000248JSmb
1 prominently state that the enrollee must sign and return
2 the acknowledgment to initiate the grievance. If an
3 organization does not require a signed acknowledgment, an
4 oral grievance shall be initiated at the time of the
5 telephone call.
6 Upon receipt of a grievance, the organization shall
7 provide notice specifying what information must be
8 provided to the organization in order to render a decision on
9 the grievance.
10 Except as authorized in this subsection, an organization
11 shall designate personnel to accept the filing of an
12 enrollee's grievance by toll-free telephone no less than
13 40 hours per week during normal business hours and, shall
14 have a telephone system available to take calls during other
15 than normal business hours and shall respond to all such
16 calls no later than the next business day after the call was
17 recorded. An organization may, in the alternative, designate
18 personnel to accept the filing of an enrollee's grievance by
19 toll-free telephone not less than 40 hours per week during
20 normal business hours and, in the case of grievances subject
21 to item (i) of subsection (d) of this Section, on a 24
22 hour a day, 7 day a week basis.
23 (d) Within 15 business days of receipt of the
24 grievance, the organization shall provide written
25 acknowledgment of the grievance, including the name,
26 address, and telephone number of the individual or department
27 designated by the organization to respond to the grievance.
28 All grievances shall be resolved in an expeditious manner,
29 and in any event, no more than (i) 48 hours after the
30 receipt of all necessary information when a delay would
31 significantly increase the risk to an enrollee's health,
32 (ii) 30 days after the receipt of all necessary information
33 in the case of requests for referrals or determinations
34 concerning whether a requested benefit is covered pursuant
-10- LRB9000248JSmb
1 to the contract, and (iii) 45 days after the receipt of all
2 necessary information in all other instances.
3 (e) The organization shall designate one or more
4 qualified personnel to review the grievance. When the
5 grievance pertains to clinical matters, the personnel shall
6 include, but not be limited to, one or more licensed,
7 certified, or registered health care professionals.
8 (f) The notice of a determination of the grievance
9 shall be made in writing to the enrollee or to the enrollee's
10 designee. In the case of a determination made in conformance
11 with item (i) of subsection (d) of this Section, notice
12 shall be made by telephone directly to the enrollee with
13 written notice to follow within 3 business days.
14 (g) The notice of a determination shall include (i)
15 the detailed reasons for the determination, (ii) in cases
16 where the determination has a clinical basis, the
17 clinical rationale for the determination, and (iii) the
18 procedures for the filing of an appeal of the
19 determination, including a form for the filing of an appeal.
20 (h) An enrollee or an enrollee's designee shall
21 have not less than 60 business days after receipt of notice
22 of the grievance determination to file a written appeal,
23 which may be submitted by letter or by a form supplied by the
24 organization.
25 (i) Within 15 business days of receipt of the appeal,
26 the organization shall provide written acknowledgment of
27 the appeal, including the name, address, and telephone number
28 of the individual designated by the organization to
29 respond to the appeal and what additional information, if
30 any, must be provided in order for the organization to render
31 a decision.
32 (j) The determination of an appeal on a clinical matter
33 must be made by personnel qualified to review the appeal,
34 including licensed, certified, or registered health care
-11- LRB9000248JSmb
1 professionals who did not make the initial
2 determination, at least one of whom must be a clinical
3 peer reviewer as defined in Article VII. The determination
4 of an appeal on a matter which is not clinical shall be made
5 by qualified personnel at a higher level than the personnel
6 who made the grievance determination.
7 (k) The organization shall seek to resolve all
8 appeals in the most expeditious manner and shall make a
9 determination and provide notice no more than (i) 2
10 business days after the receipt of all necessary information
11 when a delay would significantly increase the risk to an
12 enrollee's health and (ii) 30 business days after the receipt
13 of all necessary information in all other instances.
14 (l) The notice of a determination on an appeal shall
15 include (i) the detailed reasons for the determination and
16 (ii) in cases where the determination has a clinical
17 basis, the clinical rationale for the determination.
18 (m) An organization shall not retaliate or take any
19 discriminatory action against an enrollee because an
20 enrollee has filed a grievance or appeal.
21 (n) An organization shall maintain a file on each
22 grievance and associated appeal, if any, that shall
23 include the date the grievance was filed, a copy of the
24 grievance, if any, the date of receipt of and a copy of
25 the enrollee's acknowledgment of the grievance, if any,
26 the determination made by the organization including the date
27 of the determination and the titles and, in the case of a
28 clinical determination, the credentials of the organization's
29 personnel who reviewed the grievance. If an enrollee files
30 an appeal of the grievance, the file shall include the date
31 and a copy of the enrollee's appeal, the determination made
32 by the organization including the date of the determination
33 and the titles and, in the case of clinical determinations,
34 the credentials, of the organization's personnel who reviewed
-12- LRB9000248JSmb
1 the appeal.
2 (o) The rights and remedies conferred in this Section
3 upon enrollees are cumulative and in addition to and not
4 in lieu of any other rights or remedies available under law.
5 (215 ILCS 125/2-1.3 new)
6 Sec. 2-1.3. Health care professional applications and
7 terminations.
8 (a) A health maintenance organization shall, upon
9 request, make available and disclose to health care
10 professionals written application procedures and minimum
11 qualification requirements that a health care professional
12 must meet in order to be considered by the health
13 maintenance organization. The plan shall consult with
14 appropriately qualified health care professionals in
15 developing its qualification requirements.
16 (b) A health maintenance organization shall not
17 terminate a contract with a health care professional unless
18 the health maintenance organization provides to the
19 health care professional a written explanation of the
20 reasons for the proposed contract termination and an
21 opportunity for a review or hearing as hereinafter provided.
22 This Section shall not apply in cases involving imminent harm
23 to patient care, a determination of fraud, or a final
24 disciplinary action by a state licensing board or other
25 governmental agency that impairs the health care
26 professional's ability to practice.
27 The notice of the proposed contract termination provided
28 by the health maintenance organization to the health care
29 professional shall include:
30 (1) the reasons for the proposed action;
31 (2) notice that the health care professional has the
32 right to request a hearing or review, at the
33 professional's discretion, before a panel appointed by
-13- LRB9000248JSmb
1 the health maintenance organization;
2 (3) a time limit of not less than 30 days within
3 which a health care professional may request a hearing;
4 and
5 (4) a time limit for a hearing date which must be
6 held within 30 days after the date of receipt of a
7 request for a hearing.
8 The hearing panel shall be comprised of 3 persons
9 appointed by the health care plan. At least one person on the
10 panel shall be a clinical peer in the same discipline and the
11 same or similar specialty as the health care professional
12 under review. The hearing panel may consist of more than 3
13 persons, however, the number of clinical peers on the
14 panel shall constitute one-third or more of the total
15 membership of the panel.
16 The hearing panel shall render a decision on the
17 proposed action in a timely manner. The decision shall
18 include reinstatement of the health care professional by the
19 health care plan, provisional reinstatement subject to
20 conditions set forth by the health care plan or termination
21 of the health care professional. The decision shall be
22 provided in writing to the health care professional.
23 A decision by the hearing panel to terminate a health
24 care professional shall be effective not less than 30 days
25 after the receipt by the health care professional of the
26 hearing panel's decision.
27 (c) Upon 60 days notice to the other party, either party
28 to a contract may exercise a right of non-renewal at the
29 expiration of the contract period set forth therein or,
30 for a contract without a specific expiration date, on
31 each January 1 occurring after the contract has been in
32 effect for at least one year; provided, however, that any
33 non-renewal shall not constitute a termination for
34 purposes of this Section.
-14- LRB9000248JSmb
1 (d) A health maintenance organization shall develop and
2 implement policies and procedures to ensure that health care
3 professionals are regularly informed of information
4 maintained by the health maintenance organization to evaluate
5 the performance or practice of the health care
6 professional. The health maintenance organization shall
7 consult with health care professionals in developing
8 methodologies to collect and analyze health care professional
9 profiling data. Health maintenance organizations shall
10 provide any the information and profiling data and analysis
11 to health care professionals. The information, data, or
12 analysis shall be provided on a periodic basis appropriate
13 to the nature and amount of data and the volume and scope
14 of services provided. Any profiling data used to evaluate
15 the performance or practice of a health care professional
16 shall be measured against stated criteria and an
17 appropriate group of health care professionals using
18 similar treatment modalities serving a comparable patient
19 population. Upon presentation of the information or data,
20 each health care professional shall be given the
21 opportunity to discuss the unique nature of the health care
22 professional's patient population that may have a bearing on
23 the health care professional's profile and to work
24 cooperatively with the health maintenance organization to
25 improve performance.
26 (e) No health maintenance organization shall terminate a
27 contract or employment, or refuse to renew a contract,
28 solely because a health care provider has:
29 (1) advocated on behalf of an enrollee;
30 (2) filed a complaint against the health
31 maintenance organization;
32 (3) appealed a decision of the health maintenance
33 organization; or
34 (4) requested a hearing or review pursuant to this
-15- LRB9000248JSmb
1 Section.
2 (f) Except as provided herein, no contract or
3 agreement between a health maintenance organization and a
4 health care professional shall contain any provision that
5 supersedes or impairs a health care professional's right
6 to notice of reasons for termination and the opportunity
7 for a hearing or review concerning termination.
8 (g) Any contract provision in violation of this Section
9 is void and unenforceable.
10 (215 ILCS 125/2-1.4 new)
11 Sec. 2-1.4. Prohibitions.
12 (a) No health maintenance organization shall by contract
13 or written policy or written procedure prohibit or restrict
14 any health care provider from disclosing to any
15 subscriber, enrollee, patient, designated representative
16 or, where appropriate, prospective enrollee, (hereinafter
17 collectively referred to as enrollee) any information that
18 the provider deems appropriate regarding:
19 (1) a condition or a course of treatment with an
20 enrollee including the availability of other therapies,
21 consultations, or tests; or
22 (2) the provisions, terms, or requirements of the
23 health maintenance organization's products as they relate
24 to the enrollee, where applicable.
25 (b) No health maintenance organization shall, by
26 contract, written policy, or written procedure prohibit or
27 restrict any health care provider from filing a complaint,
28 making a report, or commenting to an appropriate governmental
29 body regarding the policies or practices of the health
30 maintenance organization that the provider believes may
31 negatively impact upon the quality of, or access to, patient
32 care.
33 (c) No health maintenance organization shall by
-16- LRB9000248JSmb
1 contract, written policy, or written procedure prohibit or
2 restrict any health care provider from advocating to the
3 health maintenance organization on behalf of the enrollee for
4 approval or coverage of a particular course of treatment or
5 for the provision of health care services.
6 (d) No contract or agreement between a health
7 maintenance organization and a health care provider shall
8 contain any clause purporting to transfer to the health
9 care provider, other than a medical group, by indemnification
10 or otherwise any liability relating to activities, actions,
11 or omissions of the health maintenance organization as
12 opposed to those of the health care provider.
13 (e) Any contract provision, written policy or
14 written procedure in violation of this Section is void and
15 unenforceable.
16 (215 ILCS 125/2-1.5 new)
17 Sec. 2-1.5 Network of providers.
18 (a) The Director, at the time of initial licensure, at
19 least every 3 years thereafter, and upon application for
20 expansion of service area, shall ensure that the health
21 maintenance organization maintains a network of health care
22 providers adequate to meet the comprehensive health
23 needs of its enrollees and to provide an appropriate choice
24 of providers sufficient to provide the services covered under
25 its enrollee's contracts by determining that:
26 (1) there are a sufficient number of
27 geographically accessible participating providers;
28 (2) there are opportunities to select from at least
29 3 primary care providers pursuant to travel and
30 distance time standards, providing that these standards
31 account for the conditions of accessing providers in
32 rural areas;
33 (3) there are sufficient providers in each area of
-17- LRB9000248JSmb
1 specialty practice to meet the needs of the enrollment
2 population; and
3 (4) there is no exclusion of any appropriately
4 licensed type of provider as a class.
5 (b) The following criteria shall be considered by the
6 Director at the time of a review:
7 (1) the availability of appropriate and timely care
8 that is provided in compliance with the standards of
9 the federal Americans with Disabilities Act to assure
10 access to health care for the enrollee population;
11 (2) the network's ability to provide culturally
12 and linguistically competent care to meet the needs
13 of the enrollee population; and
14 (3) with the exception of initial licensure,
15 the number of grievances filed by enrollees relating
16 to waiting times for appointments, appropriateness of
17 referrals, and other indicators of plan capacity.
18 (c) Each organization shall report on an annual basis
19 the number of enrollees and the number of participating
20 providers in each organization.
21 (d) If a health maintenance organization determines that
22 it does not have a health care provider with appropriate
23 training and experience in its panel or network to meet the
24 particular health care needs of an enrollee, the health
25 maintenance organization shall make a referral to an
26 appropriate provider, pursuant to a treatment plan approved
27 by the health maintenance organization in consultation
28 with the primary care provider, the non-participating
29 provider, and the enrollee or enrollee's designee, at no
30 additional cost to the enrollee beyond what the enrollee
31 would otherwise pay for services received within the network.
32 (e) a health maintenance organization shall have a
33 procedure by which an enrollee who needs ongoing care from
34 a specialist may receive a standing referral to the
-18- LRB9000248JSmb
1 specialist. If the health maintenance organization, or the
2 primary care provider in consultation with the medical
3 director of the organization and specialist if any,
4 determines that a standing referral is appropriate, the
5 organization shall make such a referral to a specialist. In
6 no event shall a health maintenance organization be
7 required to permit an enrollee to elect to have a
8 non-participating specialist, except pursuant to the
9 provisions of subsection (d). The referral shall be pursuant
10 to a treatment plan approved by the health maintenance
11 organization in consultation with the primary care provider,
12 the specialist, and the enrollee or the enrollee's
13 designee. The treatment plan may limit the number of visits
14 or the period during which visits are authorized and may
15 require the specialist to provide the primary care provider
16 with regular updates on the specialty care provided, as well
17 as all necessary medical information.
18 (f) A health maintenance organization shall have a
19 procedure by which a new enrollee, upon enrollment, or an
20 enrollee, upon diagnosis, with (i) a life-threatening
21 condition or disease, or (ii) a degenerative and disabling
22 condition or disease, either of which requires specialized
23 medical care over a prolonged period of time, may receive a
24 referral to a specialist with expertise in treating the
25 life-threatening or degenerative and disabling disease or
26 condition who shall be responsible for and capable of
27 providing and coordinating the enrollee's primary and
28 specialty care. If the health maintenance organization, or
29 primary care provider in consultation with a medical director
30 of the organization and a specialist, if any, determines that
31 the enrollee's care would most appropriately be
32 coordinated by such a specialist, the organization shall
33 refer the enrollee to such specialist. In no event shall a
34 health maintenance organization be required to permit an
-19- LRB9000248JSmb
1 enrollee to elect to have a non-participating specialist,
2 except pursuant to the provisions of subsection (d). The
3 referral shall be pursuant to a treatment plan approved
4 by the health maintenance organization, in consultation with
5 the primary care provider if appropriate, the specialist, and
6 the enrollee or the enrollee's designee. The specialist
7 shall be permitted to treat the enrollee without a
8 referral from the enrollee's primary care provider and
9 may authorize such referrals, procedures, tests, and
10 other medical services as the enrollee's primary care
11 provider would otherwise be permitted to provide or
12 authorize, subject to the terms of the treatment plan. If an
13 organization refers an enrollee to a non-participating
14 provider, services provided pursuant to the approved
15 treatment plan shall be provided at no additional cost to
16 the enrollee beyond what the enrollee would otherwise pay
17 for services received within the network.
18 (g) A health maintenance organization shall have a
19 procedure by which an enrollee with (i) a life-threatening
20 condition or disease or (ii) a degenerative and disabling
21 condition or disease, either of which requires
22 specialized medical care over a prolonged period of time,
23 may receive a referral to a specialty care center with
24 expertise in treating the life-threatening or degenerative
25 and disabling disease or condition. If the health maintenance
26 organization, or the primary care provider or the specialist
27 designated pursuant to subsection (f), in consultation with
28 a medical director of the organization, determines that the
29 enrollee's care would most appropriately be provided by a
30 specialty care center, the organization shall refer the
31 enrollee to a specialty care center. In no event shall a
32 health maintenance organization be required to permit an
33 enrollee to elect to have a non-participating specialty
34 care center, unless the organization does not have an
-20- LRB9000248JSmb
1 appropriate specialty care center to treat the enrollee's
2 disease or condition within its network. The referral shall
3 be pursuant to a treatment plan developed by the
4 specialty care center and approved by the health maintenance
5 organization, in consultation with the primary care provider,
6 if any, or a specialist designated pursuant to subsection
7 (f), and the enrollee or the enrollee's designee. If an
8 organization refers an enrollee to a specialty care center
9 that does not participate in the organization's network,
10 services provided pursuant to the approved treatment
11 plan shall be provided at no additional cost to the enrollee
12 beyond what the enrollee would otherwise pay for
13 services received within the network. For purposes of this
14 subsection, a specialty care center shall mean only those
15 centers that are accredited or designated by an agency of
16 the state or federal government or by a voluntary national
17 health organization as having special expertise in treating
18 the life-threatening disease or condition or degenerative
19 and disabling disease or condition for which it is
20 accredited or designated.
21 (h) If an enrollee's health care provider leaves the
22 health maintenance organization's network of providers for
23 reasons other than those for which the provider would not be
24 eligible to receive a hearing pursuant to subsection (b) of
25 Section 2-1.3, the health maintenance organization shall
26 permit the enrollee to continue an ongoing course of
27 treatment with the enrollee's current health care provider
28 during a transitional period of:
29 (1) up to 90 days from the date of notice to the
30 enrollee of the provider's disaffiliation from the
31 organization's network; or
32 (2) if the enrollee has entered the second trimester
33 of pregnancy at the time of the provider's
34 disaffiliation, for a transitional period that
-21- LRB9000248JSmb
1 includes the provision of post-partum care directly
2 related to the delivery.
3 Transitional care, however, shall be authorized by the
4 health maintenance organization during the transitional
5 period only if the health care provider agrees (i) to
6 continue to accept reimbursement from the health maintenance
7 organization at the rates applicable prior to the start of
8 the transitional period as payment in full, (ii) to adhere
9 to the organization's quality assurance requirements and to
10 provide to the organization necessary medical information
11 related to the care, and (iii) to otherwise adhere to the
12 organization's policies and procedures, including but not
13 limited to procedures regarding referrals and obtaining
14 pre-authorization and a treatment plan approved by the
15 organization.
16 (i) If a new enrollee whose health care provider is
17 not a member of the health maintenance organization's
18 provider network enrolls in the health maintenance
19 organization, the organization shall permit the enrollee
20 to continue an ongoing course of treatment with the
21 enrollee's current health care provider during a transitional
22 period of up to 60 days from the effective date of
23 enrollment, if (i) the enrollee has a life-threatening
24 disease or condition or a degenerative and disabling
25 disease or condition or (ii) the enrollee has entered the
26 second trimester of pregnancy at the effective date of
27 enrollment, in which case the transitional period shall
28 include the provision of post-partum care directly
29 related to the delivery. If an enrollee elects to continue
30 to receive care from a health care provider pursuant to this
31 subsection, the care shall be authorized by the health
32 maintenance organization for the transitional period only
33 if the health care provider agrees (i) to accept
34 reimbursement from the health maintenance organization at
-22- LRB9000248JSmb
1 rates established by the health maintenance organization as
2 payment in full, which rates shall be no more than the level
3 of reimbursement applicable to similar providers within
4 the health maintenance organization's network for those
5 services, (ii) to adhere to the organization's quality
6 assurance requirements and agrees to provide to the
7 organization necessary medical information related to
8 the care, and (iii) to otherwise adhere to the organization's
9 policies and procedures including, but not limited to,
10 procedures regarding referrals and obtaining
11 pre-authorization and a treatment plan approved by the
12 organization. In no event shall this subsection be
13 construed to require a health maintenance organization to
14 provide coverage for benefits not otherwise covered or to
15 diminish or impair pre-existing condition limitations
16 contained within the subscriber's contract.
17 (215 ILCS 125/2-1.6 new)
18 Sec. 2-1.6. Duty to report.
19 (a) A health maintenance organization shall make a
20 report to the appropriate professional disciplinary agency
21 within 30 days of the occurrence of any of the following:
22 (1) the termination of a health care provider
23 contract pursuant to Section 2-1.3 for reasons relating
24 to alleged mental or physical impairment, misconduct, or
25 impairment of patient safety or welfare;
26 (2) the voluntary or involuntary termination of a
27 contract or employment or other affiliation with such
28 organization to avoid the imposition of disciplinary
29 measures; or
30 (3) the termination of a health care provider
31 contract in the case of a determination of fraud or in a
32 case of imminent harm to patient health.
33 (b) An organization shall make a report to be made to
-23- LRB9000248JSmb
1 the appropriate professional disciplinary agency within 60
2 days of obtaining knowledge of any information that
3 reasonably appears to show that a health professional is
4 guilty of professional misconduct.
5 (c) Reports of possible professional misconduct made
6 pursuant to this Section shall be made in writing to the
7 appropriate professional disciplinary agency. Written
8 reports shall include the name, address, profession, and
9 license number of the individual and a description of the
10 action taken by the organization, including the reason
11 for the action and the date thereof, or the nature of the
12 action or conduct that led to the resignation, termination of
13 contract, or withdrawal, and the date thereof.
14 (d) Any report or information furnished to an
15 appropriate professional discipline agency in accordance
16 with the provisions of this Section shall be deemed a
17 confidential communication and shall not be subject to
18 inspection or disclosure in any manner except upon formal
19 written request by a duly authorized public agency or
20 pursuant to a judicial subpoena issued in a pending action
21 or proceeding.
22 (e) Any person, facility, organization, or corporation
23 that makes a report pursuant to this Section in good faith
24 without malice shall have immunity from any liability,
25 civil or criminal, for having made the report. For purposes
26 of any proceeding, civil or criminal, the good faith of
27 any person required to make a report shall be presumed.
28 (215 ILCS 125/2-1.7 new)
29 Sec. 2-1.7. Disclosure of information.
30 (a) Each health care professional affiliated with a
31 health maintenance organization shall, upon request, provide
32 to his or her patient or prospective patient the following:
33 (1) information related to the health care
-24- LRB9000248JSmb
1 professional's educational background, experience,
2 training, specialty, and board certification, if
3 applicable;
4 (2) information regarding the health care
5 professional's participation in continuing education
6 programs and compliance with any licensure,
7 certification, or registration requirements, if
8 applicable; and
9 (3) information regarding the health care
10 professional's participation in clinical performance
11 reviews conducted by the department where applicable and
12 where available.
13 (b) Nothing contained in this Section shall require
14 written disclosure of the information described in
15 subsection (a) by the health care professional to the
16 patient.
17 (215 ILCS 125/Art. VII heading new)
18 ARTICLE VII. UTILIZATION REVIEW
19 (215 ILCS 125/7-1 new)
20 Sec. 7-1. This Article may be cited as the Utilization
21 Review Law.
22 (215 ILCS 125/7-5 new)
23 Sec. 7-5. Definitions. For purposes of this Article:
24 "Adverse determination" means a determination by a
25 utilization review agent that an admission, extension of
26 stay or other health care service has been reviewed and,
27 based on the information provided, is not medically
28 necessary.
29 "Clinical peer reviewer" means:
30 (1) a licensed physician and, in connection with
31 an appeal of an adverse determination, a licensed
-25- LRB9000248JSmb
1 physician who is in the same or similar specialty as the
2 health care provider who typically manages the
3 medical condition, procedure or treatment under review;
4 or
5 (2) in the case of non-physician reviewers, a
6 health care professional who is in the same
7 profession and same or similar specialty as the health
8 care provider who typically manages the medical
9 condition, procedure or treatment under review. Nothing
10 herein shall be construed to change any statutorily
11 defined scope of practice.
12 "Emergency condition" means a medical or behavioral
13 condition, the onset of which is sudden, that manifests
14 itself by symptoms of sufficient severity, including
15 severe pain, that a prudent layperson, possessing an
16 average knowledge of medicine and health, could reasonably
17 expect the absence of immediate medical attention to result
18 in:
19 (1) placing the health of the person afflicted with
20 the condition in serious jeopardy, or in the case of a
21 behavioral condition placing the health of the person
22 or others in serious jeopardy;
23 (2) serious impairment to the person's bodily
24 functions;
25 (3) serious dysfunction of any bodily organ or
26 part of the person; or
27 (4) serious disfigurement of the person.
28 "Enrollee" means a person subject to utilization review.
29 "Health care professional" means an appropriately
30 licensed, registered, or certified health care
31 professional pursuant to the laws of this State or a health
32 care professional comparably licensed, registered, or
33 certified by another state.
34 "Health care provider" means a provider as defined in
-26- LRB9000248JSmb
1 Section 1-2 of this Act.
2 "Utilization review" means the review to determine
3 whether health care services that have been provided, are
4 being provided or are proposed to be provided to a
5 patient, whether undertaken prior to, concurrent with or
6 subsequent to the delivery of such services are
7 medically necessary. For the purposes of this Article
8 none of the following shall be considered utilization review:
9 (1) denials based on failure to obtain health care
10 services from a designated or approved health care
11 provider as required under a subscriber's contract;
12 (2) the review of the appropriateness of the
13 application of a particular coding to a patient,
14 including the assignment of diagnosis and procedure;
15 (3) any issues relating to the determination of
16 the amount or extent of payment other than determinations
17 to deny payment based on an adverse determination; and
18 (4) any determination of any coverage issues other
19 than whether health care services are or were medically
20 necessary.
21 "Utilization review agent" means any company,
22 organization or other entity performing utilization review,
23 except:
24 (1) an agency of the federal government;
25 (2) an agent acting on behalf of the federal
26 government, but only to the extent that the agent is
27 providing services to the federal government;
28 (3) an agent acting on behalf of the state and
29 local government for services provided pursuant to
30 title XIX of the federal Social Security Act;
31 (4) a hospital's internal quality assurance program
32 except if associated with a health care financing
33 mechanism.
34 "Utilization review plan" means:
-27- LRB9000248JSmb
1 (1) a description of the process for developing the
2 written clinical review criteria;
3 (2) a description of the types of written clinical
4 information which the plan might consider in its clinical
5 review including, but not limited to, a set of specific
6 written clinical review criteria;
7 (3) a description of practice guidelines and
8 standards used by a utilization review agent in carrying
9 out a determination of medical necessity;
10 (4) the procedures for scheduled review and
11 evaluation of the written clinical review criteria; and
12 (5) a description of the qualifications and
13 experience of the health care professionals who
14 developed the criteria, who are responsible for periodic
15 evaluation of the criteria and of the health care
16 professionals or others who use the written clinical
17 review criteria in the process of utilization review.
18 (215 ILCS 125/7-10 new)
19 Sec. 7-10. Registration of utilization review agents.
20 (a) Every utilization review agent who conducts the
21 practice of utilization review shall biennially register
22 with the Director and report, in a statement subscribed and
23 affirmed as true under the penalties of perjury, the
24 information required pursuant to subsection (b) of this
25 Section.
26 (b) The report shall contain a description of the
27 following:
28 (1) the utilization review plan;
29 (2) the provisions by which an enrollee, the
30 enrollee's designee, or a health care provider may seek
31 reconsideration of, or appeal from, adverse
32 determinations by the utilization review agent, in
33 accordance with the provisions of this Article, including
-28- LRB9000248JSmb
1 provisions to ensure a timely appeal and that an
2 enrollee, the enrollee's designee, and, in the case of
3 an adverse determination involving a retrospective
4 determination, the enrollee's health care provider, is
5 informed of their right to appeal adverse
6 determinations;
7 (3) procedures by which a decision on a request for
8 utilization review for services requiring
9 preauthorization shall comply with timeframes
10 established pursuant to this Article;
11 (4) a description of an emergency care policy,
12 which shall include the procedures under which an
13 emergency admission shall be made or emergency treatment
14 shall be given;
15 (5) a description of the personnel utilized to
16 conduct utilization review including a description of
17 the circumstances under which utilization review may be
18 conducted by:
19 (A) administrative personnel,
20 (B) health care professionals who are not
21 clinical peer reviewers, and
22 (C) clinical peer reviewers;
23 (6) a description of the mechanisms employed to
24 assure that administrative personnel are trained in the
25 principles and procedures of intake screening and data
26 collection and are appropriately monitored by a
27 licensed health care professional while performing an
28 administrative review;
29 (7) a description of the mechanisms employed to
30 assure that health care professionals conducting
31 utilization review are:
32 (A) appropriately licensed, registered, or
33 certified and
34 (B) trained in the principles, procedures,
-29- LRB9000248JSmb
1 and standards of the utilization review agent;
2 (8) a description of the mechanisms employed to
3 assure that only a clinical peer reviewer shall render an
4 adverse determination;
5 (9) provisions to ensure that appropriate personnel
6 of the utilization review agent are reasonably accessible
7 by toll-free telephone:
8 (A) not less than 40 hours per week during
9 normal business hours, to discuss patient care and
10 allow response to telephone requests, and to ensure
11 that the utilization review agent has a telephone
12 system capable of accepting, recording, or providing
13 instruction to incoming telephone calls during
14 other than normal business hours and to ensure
15 response to accepted or recorded messages not later
16 than the next business day after the date on which
17 the call was received; or
18 (B) notwithstanding the provisions of item (1),
19 not less than 40 hours per week during normal
20 business hours, to discuss patient care and allow
21 response to telephone requests, and to ensure that,
22 in the case of a request submitted pursuant to
23 subsection (c) of Section 7-20 or an expedited
24 appeal filed pursuant to subsection (b) of Section
25 7-25, 24 hour a day, 7 day a week basis;
26 (10) the policies and procedures to ensure that
27 all applicable State and federal laws to protect the
28 confidentiality of individual medical and treatment
29 records are followed;
30 (11) a copy of the materials to be disclosed to an
31 enrollee or prospective enrollee pursuant to this Article
32 and Section 2-1.1 of this Act;
33 (12) a description of the mechanisms employed by
34 the utilization review agent to assure that all
-30- LRB9000248JSmb
1 contractors, subcontractors, subvendors, agents, and
2 employees affiliated by contract or otherwise with such
3 utilization review agent will adhere to the standards and
4 requirements of this Article; and
5 (13) a list of the payors for which the
6 utilization review agent is performing utilization
7 review in this State.
8 (c) Upon receipt of the report, the Director
9 shall issue an acknowledgment of the filing.
10 (d) A registration issued under this Article shall be
11 valid for a period of not more than 2 years, and may be
12 renewed for additional periods of not more than 2 years each.
13 (e) A health maintenance organization licensed pursuant
14 to this Act shall not be required to register as a
15 utilization review agent, provided that the health
16 maintenance organization has otherwise provided the
17 information required pursuant to subsection (b) of this
18 Section to the Director.
19 (215 ILCS 125/7-15 new)
20 Sec. 7-15. Utilization review program standards.
21 (a) A utilization review agent shall adhere to
22 utilization review program standards consistent with the
23 provisions of this Article which shall, at a minimum,
24 include:
25 (1) appointment of a medical director, who is a
26 licensed physician; provided, however, that the
27 utilization review agent may appoint a clinical director
28 when the utilization review performed is for a discrete
29 category of health care service and provided further that
30 the clinical director is a licensed health care
31 professional who typically manages the category of
32 service; responsibilities of the medical director, or,
33 where appropriate, the clinical director, shall
-31- LRB9000248JSmb
1 include, but not be limited to, the supervision and
2 oversight of the utilization review process;
3 (2) development of written policies and procedures
4 that govern all aspects of the utilization review
5 process and a requirement that a utilization review
6 agent shall maintain and make available to enrollees and
7 health care providers a written description of the
8 procedures including procedures to appeal an adverse
9 determination;
10 (3) utilization of written clinical review criteria
11 developed pursuant to a utilization review plan;
12 (4) establishment of a process for rendering
13 utilization review determinations which shall, at a
14 minimum, include written procedures to assure that
15 utilization reviews and determinations are conducted
16 within the timeframes established herein, procedures to
17 notify an enrollee, an enrollee's designee, and an
18 enrollee's health care provider of adverse
19 determinations, and procedures for appeal of adverse
20 determinations, including the establishment of an
21 expedited appeals process for denials of continued
22 inpatient care or where there is imminent or serious
23 threat to the health of the enrollee;
24 (5) establishment of a written procedure to assure
25 that the notice of an adverse determination includes:
26 (A) the reasons for the determination including
27 the clinical rationale, if any;
28 (B) instructions on how to initiate an
29 appeal; and
30 (C) notice of the availability, upon request of
31 the enrollee or the enrollee's designee, of the
32 clinical review criteria relied upon to make the
33 determination;
34 (6) establishment of a requirement that
-32- LRB9000248JSmb
1 appropriate personnel of the utilization review agent are
2 reasonably accessible by toll-free telephone:
3 (A) not less than 40 hours per week during
4 normal business hours to discuss patient care and
5 allow response to telephone requests, and to ensure
6 that such utilization review agent has a telephone
7 system capable of accepting, recording or providing
8 instruction to incoming telephone calls during
9 other than normal business hours and to ensure
10 response to accepted or recorded messages not less
11 than one business day after the date on which the
12 call was received; or
13 (B) notwithstanding the provisions of item
14 (A), not less than 40 hours per week during normal
15 business hours, to discuss patient care and allow
16 response to telephone requests, and to ensure that,
17 in the case of a request submitted pursuant to
18 subsection (c) of Section 7-20 or an expedited
19 appeal filed pursuant to subsection (b) of
20 Section 7-25, on a 24 hour a day, 7 day a week
21 basis;
22 (7) establishment of appropriate policies and
23 procedures to ensure that all applicable State and
24 federal laws to protect the confidentiality of individual
25 medical records are followed;
26 (8) establishment of a requirement that emergency
27 services rendered to an enrollee shall not be subject
28 to prior authorization nor shall reimbursement for
29 those services be denied on retrospective review;
30 provided, however, that those services are medically
31 necessary to stabilize or treat an emergency condition.
32 (b) A utilization review agent shall assure adherence to
33 the requirements stated in subsection (a) of this Section by
34 all contractors, subcontractors, subvendors, agents, and
-33- LRB9000248JSmb
1 employees affiliated by contract or otherwise with the
2 utilization review agent.
3 (215 ILCS 125/7-20 new)
4 Sec. 7-20. Utilization review determinations.
5 (a) Utilization review shall be conducted by:
6 (1) administrative personnel trained in the
7 principles and procedures of intake screening and data
8 collection, provided, however, that administrative
9 personnel shall only perform intake screening, data
10 collection, and non-clinical review functions and shall
11 be supervised by a licensed health care professional;
12 (2) a health care professional who is
13 appropriately trained in the principles, procedures,
14 and standards of such utilization review agent; provided,
15 however, that a health care professional who is not a
16 clinical peer reviewer may not render an adverse
17 determination; and
18 (3) a clinical peer reviewer where the review
19 involves an adverse determination.
20 (b) A utilization review agent shall make a utilization
21 review determination involving health care services that
22 require pre-authorization and provide notice of a
23 determination to the enrollee or enrollee's designee
24 and the enrollee's health care provider by telephone and
25 in writing within 3 business days of receipt of the necessary
26 information.
27 (c) A utilization review agent shall make a
28 determination involving continued or extended health care
29 services, or additional services for an enrollee
30 undergoing a course of continued treatment prescribed by a
31 health care provider and provide notice of the determination
32 to the enrollee or the enrollee's designee, which may be
33 satisfied by notice to the enrollee's health care provider,
-34- LRB9000248JSmb
1 by telephone and in writing within one business day of
2 receipt of the necessary information. Notification of
3 continued or extended services shall include the number of
4 extended services approved, the new total of approved
5 services, the date of onset of services, and the next review
6 date.
7 (d) A utilization review agent shall make a utilization
8 review determination involving health care services that have
9 been delivered within 30 days of receipt of the necessary
10 information.
11 (e) Notice of an adverse determination made by a
12 utilization review agent shall be in writing and must
13 include:
14 (1) the reasons for the determination including the
15 clinical rationale, if any;
16 (2) instructions on how to initiate an appeal; and
17 (3) notice of the availability, upon request of
18 the enrollee, or the enrollee's designee, of the clinical
19 review criteria relied upon to make the determination;
20 the notice shall also specify what, if any, additional
21 necessary information must be provided to, or obtained
22 by, the utilization review agent in order to render a
23 decision on the appeal.
24 (f) In the event that a utilization review agent
25 renders an adverse determination without attempting to
26 discuss the matter with the enrollee's health care
27 provider who specifically recommended the health care
28 service, procedure, or treatment under review, the health
29 care provider shall have the opportunity to request a
30 reconsideration of the adverse determination. Except in
31 cases of retrospective reviews, the reconsideration shall
32 occur within one business day of receipt of the request
33 and shall be conducted by the enrollee's health care
34 provider and the clinical peer reviewer making the initial
-35- LRB9000248JSmb
1 determination or a designated clinical peer reviewer if the
2 original clinical peer reviewer cannot be available. In
3 the event that the adverse determination is upheld after
4 reconsideration, the utilization review agent shall provide
5 notice as required pursuant to subsection (e) of this
6 Section. Nothing in this Section shall preclude the enrollee
7 from initiating an appeal from an adverse determination.
8 (215 ILCS 125/7-25 new)
9 Sec. 7-25. Appeal of adverse determinations by
10 utilization review agents.
11 (a) An enrollee, the enrollee's designee and, in
12 connection with retrospective adverse determinations, an
13 enrollee's health care provider, may appeal an adverse
14 determination rendered by a utilization review agent.
15 (b) A utilization review agent shall establish an
16 expedited appeal process for appeal of an adverse
17 determination involving:
18 (1) continued or extended health care services,
19 procedures, or treatments or additional services for an
20 enrollee undergoing a course of continued treatment
21 prescribed by a health care provider; or
22 (2) an adverse determination in which the
23 health care provider believes an immediate appeal is
24 warranted except any retrospective determination.
25 The appeal process shall include mechanisms that
26 facilitate resolution of the appeal including, but not
27 limited to, the sharing of information from the
28 enrollee's health care provider and the utilization review
29 agent by telephonic means or by facsimile. The utilization
30 review agent shall provide reasonable access to its
31 clinical peer reviewer within one business day of receiving
32 notice of the taking of an expedited appeal. Expedited
33 appeals must be determined within 2 business days of receipt
-36- LRB9000248JSmb
1 of necessary information to conduct the appeal. Expedited
2 appeals that do not result in a resolution satisfactory to
3 the appealing party may be further appealed through the
4 standard appeal process.
5 (c) A utilization review agent shall establish a
6 standard appeal process that includes procedures for appeals
7 to be filed in writing or by telephone. A utilization
8 review agent must establish a period of no less than 45 days
9 after receipt of notification by the enrollee of the initial
10 utilization review determination and receipt of all
11 necessary information to file the appeal from the
12 determination. The utilization review agent must provide
13 written acknowledgment of the filing of the appeal to the
14 appealing party within 15 days of the filing and shall make a
15 determination with regard to the appeal within 60 days of
16 the receipt of necessary information to conduct the
17 appeal. The utilization review agent shall notify the
18 enrollee, the enrollee's designee and, where appropriate,
19 the enrollee's health care provider, in writing, of the
20 appeal determination within 2 business days of the rendering
21 of the determination. The notice of the appeal determination
22 shall include the reasons for the determination; provided,
23 however, that where the adverse determination is upheld on
24 appeal, the notice shall include the clinical rationale
25 for the determination.
26 (d) Both expedited and standard appeals shall be
27 reviewed by a clinical peer reviewer other than the
28 clinical peer reviewer who rendered the adverse
29 determination.
30 (215 ILCS 125/7-30 new)
31 Sec. 7-30. Required and prohibited practices.
32 (a) A utilization review agent shall have written
33 procedures for assuring that patient-specific information
-37- LRB9000248JSmb
1 obtained during the process of utilization review will be:
2 (1) kept confidential in accordance with applicable
3 State and federal laws; and
4 (2) shared only with the enrollee, the
5 enrollee's designee, the enrollee's health care provider,
6 and those who are authorized by law to receive the
7 information.
8 (b) Summary data shall not be considered confidential
9 if it does not provide information to allow identification of
10 individual patients.
11 (c) Any health care professional who makes
12 determinations regarding the medical necessity of health care
13 services during the course of utilization review shall be
14 appropriately licensed, registered, or certified.
15 (d) A utilization review agent shall not, with respect
16 to utilization review activities, permit or provide
17 compensation or anything of value to its employees, agents,
18 or contractors based on:
19 (1) either a percentage of the amount by which a
20 claim is reduced for payment or the number of claims or
21 the cost of services for which the person has denied
22 authorization or payment; or
23 (2) any other method that encourages the
24 rendering of an adverse determination.
25 (e) If a health care service has been specifically
26 pre-authorized or approved for an enrollee by a
27 utilization review agent, a utilization review agent shall
28 not, pursuant to retrospective review, revise or modify
29 the specific standards, criteria, or procedures used for
30 the utilization review for procedures, treatment, and
31 services delivered to the enrollee during the same course
32 of treatment.
33 (f) Utilization review shall not be conducted more
34 frequently than is reasonably required to assess whether the
-38- LRB9000248JSmb
1 health care services under review are medically necessary.
2 (g) When making prospective, concurrent, and
3 retrospective determinations, utilization review agents shall
4 collect only such information as is necessary to make the
5 determination and shall not routinely require health care
6 providers to numerically code diagnoses or procedures to
7 be considered for certification or routinely request copies
8 of medical records of all patients reviewed. During
9 prospective or concurrent review, copies of medical
10 records shall only be required when necessary to verify that
11 the health care services subject to the review are medically
12 necessary. In these cases, only the necessary or relevant
13 sections of the medical record shall be required. A
14 utilization review agent may request copies of partial or
15 complete medical records retrospectively.
16 (h) In no event shall information be obtained from
17 the health care providers for the use of the utilization
18 review agent by persons other than health care professionals,
19 medical record technologists, or administrative personnel who
20 have received appropriate training.
21 (i) The utilization review agent shall not undertake
22 utilization review at the site of the provision of health
23 care services unless the utilization review agent:
24 (1) identifies himself or herself by name and the
25 name of his or her organization, including displaying
26 photographic identification that includes the name of
27 the utilization review agent and clearly identifies the
28 individual as representative of the utilization review
29 agent;
30 (2) whenever possible, schedules review at least
31 one business day in advance with the appropriate health
32 care provider;
33 (3) if requested by a health care provider,
34 assures that the on-site review staff register with the
-39- LRB9000248JSmb
1 appropriate contact person, if available, prior to
2 requesting any clinical information or assistance
3 from the health care provider;
4 (4) obtains consent from the enrollee or the
5 enrollee's designee before interviewing the patient's
6 family, or observing any health care service being
7 provided to the enrollee; and
8 (5) this subsection shall not apply to health
9 care professionals engaged in providing care, case
10 management, or making on-site discharge decisions.
11 (j) A utilization review agent shall not base an adverse
12 determination on a refusal to consent to observing any health
13 care service.
14 (k) A utilization review agent shall not base an adverse
15 determination on lack of reasonable access to a health
16 care provider's medical or treatment records unless the
17 utilization review agent has provided reasonable notice
18 to the enrollee, the enrollee's designee, or the
19 enrollee's health care provider, in which case the
20 enrollee must be notified, and has complied with all
21 provisions of subsection (i) of this Section.
22 (l) Neither the utilization review agent nor the entity
23 for which the agent provides utilization review shall take
24 any action with respect to a patient or a health care
25 provider that is intended to penalize the enrollee, the
26 enrollee's designee, or the enrollee's health care provider
27 for, or to discourage the enrollee, the enrollee's designee,
28 or the enrollee's health care provider from undertaking an
29 appeal, dispute resolution, or judicial review of an adverse
30 determination.
31 (m) In no event shall an enrollee, an enrollee's
32 designee, an enrollee's health care provider, any other
33 health care provider, or any other person or entity, be
34 required to inform or contact the utilization review agent
-40- LRB9000248JSmb
1 prior to the provision of emergency care, including emergency
2 treatment or emergency admission.
3 (n) No contract or agreement between a utilization
4 review agent and a health care provider shall contain any
5 clause purporting to transfer to the health care provider by
6 indemnification or otherwise any liability relating to
7 activities, actions, or omissions of the utilization review
8 agent as opposed to the health care provider.
9 (o) A health care professional providing health care
10 services to an enrollee shall be prohibited from serving
11 as the clinical peer reviewer for that enrollee in connection
12 with the health care services being provided to the
13 enrollee.
14 (215 ILCS 125/7-35 new)
15 Sec. 7-35. Waiver. Any agreement that purports to waive,
16 limit, disclaim, or in any way diminish the rights set forth
17 in this Article is void as contrary to public policy.
18 (215 ILCS 125/7-40 new)
19 Sec. 7-40. Rights and remedies. The rights and remedies
20 conferred in this Article upon enrollees and health care
21 providers are cumulative and in addition to and not in lieu
22 of any other rights or remedies available under law.
23 (215 ILCS 125/4-6 rep.)
24 Section 10. The Health Maintenance Organization Act is
25 amended by repealing Section 4-6.