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90_HB0626ham001
LRB9000248JSgcam01
1 AMENDMENT TO HOUSE BILL 626
2 AMENDMENT NO. . Amend House Bill 626 by replacing
3 everything after the enacting clause with the following:
4 "Section 1. Short title. This Act may be cited as the
5 Managed Care Entity Responsibility and Patient Rights Act.
6 Section 5. Definitions. For purposes of this Act:
7 "Adverse determination" means a determination by a
8 utilization review agent that an admission, extension of
9 stay or other health care service has been reviewed and,
10 based on the information provided, is not medically
11 necessary.
12 "Clinical peer reviewer" means:
13 (1) a licensed physician and, in connection with
14 an appeal of an adverse determination, a licensed
15 physician who is in the same or similar specialty as the
16 health care provider who typically manages the
17 medical condition, procedure or treatment under review;
18 or
19 (2) in the case of non-physician reviewers, a
20 health care professional who is in the same
21 profession and same or similar specialty as the health
22 care provider who typically manages the medical
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1 condition, procedure or treatment under review. Nothing
2 herein shall be construed to change any statutorily
3 defined scope of practice.
4 "Director" means the Director of Public Health.
5 "Emergency condition" means a medical or behavioral
6 condition, the onset of which is sudden, that manifests
7 itself by symptoms of sufficient severity, including
8 severe pain, that a prudent lay person, possessing an
9 average knowledge of medicine and health, could reasonably
10 expect the absence of immediate medical attention to result
11 in:
12 (1) placing the health of the person afflicted with
13 the condition in serious jeopardy, or in the case of a
14 behavioral condition placing the health of the person
15 or others in serious jeopardy;
16 (2) serious impairment to the person's bodily
17 functions;
18 (3) serious dysfunction of any bodily organ or
19 part of the person; or
20 (4) serious disfigurement of the person.
21 "Enrollee" means a person who has been enrolled in a
22 health care or managed care plan.
23 "Health care professional" means an appropriately
24 licensed, registered, or certified health care
25 professional pursuant to the laws of this State or a health
26 care professional comparably licensed, registered, or
27 certified by another state.
28 "Health care provider" means a physician, hospital
29 facility, or other person licensed or otherwise authorized to
30 furnish health care services and also includes any other
31 entity that arranges for the delivery or furnishing of health
32 care services.
33 "Health care services" means services included in the (i)
34 furnishing of medical or dental care, (ii) hospitalization
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1 incident to the furnishing of medical or dental care, and
2 (iii) furnishing of services for the purpose of preventing,
3 alleviating, curing, or healing human illness or injury to an
4 individual.
5 "Managed care plan" means a plan that establishes,
6 operates, or maintains a network of health care providers
7 that have entered into agreements with the plan to provide
8 health care services to enrollees where the plan has the
9 ultimate and direct contractual obligation to the enrollee to
10 arrange for the provision of or pay for services through:
11 (1) organizational arrangements for ongoing quality
12 assurance, utilization review programs, or dispute
13 resolution; or
14 (2) financial incentives for persons enrolled in
15 the plan to use the participating providers and
16 procedures covered by the plan.
17 A managed care plan may be established or operated by any
18 entity including a licensed insurance company, hospital or
19 medical service plan, health maintenance organization,
20 limited health service organization, preferred provider
21 organization, third party administrator, or an employer or
22 employee organization.
23 "Subscriber" means a person or entity that has entered
24 into a contractual relationship with a managed care plan for
25 the provision of or arrangement for health care services to
26 the beneficiaries of the contract.
27 "Utilization review" means the review to determine
28 whether health care services that have been provided, are
29 being provided or are proposed to be provided to a
30 patient, whether undertaken prior to, concurrent with or
31 subsequent to the delivery of such services are
32 medically necessary. For the purposes of this Act none
33 of the following shall be considered utilization review:
34 (1) denials based on failure to obtain health care
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1 services from a designated or approved health care
2 provider as required under a subscriber's contract;
3 (2) the review of the appropriateness of the
4 application of a particular coding to a patient,
5 including the assignment of diagnosis and procedure;
6 (3) any issues relating to the determination of
7 the amount or extent of payment other than determinations
8 to deny payment based on an adverse determination; and
9 (4) any determination of any coverage issues other
10 than whether health care services are or were medically
11 necessary.
12 "Utilization review agent" means any company,
13 organization, or other entity performing utilization review,
14 except:
15 (1) an agency of the federal government;
16 (2) an agent acting on behalf of the federal
17 government, but only to the extent that the agent is
18 providing services to the federal government;
19 (3) an agent acting on behalf of the state and
20 local government for services provided pursuant to
21 title XIX of the federal Social Security Act;
22 (4) a hospital's internal quality assurance program
23 except if associated with a health care financing
24 mechanism.
25 "Utilization review plan" means:
26 (1) a description of the process for developing the
27 written clinical review criteria;
28 (2) a description of the types of written clinical
29 information which the plan might consider in its clinical
30 review including, but not limited to, a set of specific
31 written clinical review criteria;
32 (3) a description of practice guidelines and
33 standards used by a utilization review agent in carrying
34 out a determination of medical necessity;
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1 (4) the procedures for scheduled review and
2 evaluation of the written clinical review criteria; and
3 (5) a description of the qualifications and
4 experience of the health care professionals who
5 developed the criteria, who are responsible for periodic
6 evaluation of the criteria and of the health care
7 professionals or others who use the written clinical
8 review criteria in the process of utilization review.
9 Section 10. Disclosure of information.
10 (a) An enrollee, and upon request a prospective enrollee
11 prior to enrollment, shall be supplied with written
12 disclosure information which may be incorporated into the
13 member handbook or the subscriber contract or
14 certificate containing at least the information specified
15 in this Section. In the event of any inconsistency between
16 any separate written disclosure statement and the
17 subscriber contract or certificate, the terms of the
18 subscriber contract or certificate shall be controlling.
19 The information to be disclosed shall include, at a
20 minimum, all of the following:
21 (1) A description of coverage provisions, health
22 care benefits, benefit maximums, including benefit
23 limitations, and exclusions of coverage, including the
24 definition of medical necessity used in determining
25 whether benefits will be covered.
26 (2) A description of all prior authorization or
27 other requirements for treatments and services.
28 (3) A description of utilization review policies
29 and procedures used by the managed care plan
30 including the circumstances under which utilization
31 review will be undertaken, the toll-free telephone
32 number of the utilization review agent, the timeframes
33 under which utilization review decisions must be made for
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1 prospective, retrospective, and concurrent decisions,
2 the right to reconsideration, the right to an appeal,
3 including the expedited and standard appeals processes
4 and the timeframes for those appeals, the right to
5 designate a representative, a notice that all denials of
6 claims will be made by qualified clinical personnel
7 and that all notices of denials will include information
8 about the basis of the decision, and further appeal
9 rights, if any.
10 (4) A description prepared annually of the types of
11 methodologies the managed care plan uses to reimburse
12 providers specifying the type of methodology that is
13 used to reimburse particular types of providers or
14 reimburse for the provision of particular types of
15 services; provided, however, that nothing in this item
16 should be construed to require disclosure of individual
17 contracts or the specific details of any financial
18 arrangement between a managed care plan and a health care
19 provider.
20 (5) An explanation of a subscriber's financial
21 responsibility for payment of premiums, coinsurance,
22 co-payments, deductibles, and any other charges, annual
23 limits on a subscriber's financial responsibility, caps
24 on payments for covered services and financial
25 responsibility for non-covered health care procedures,
26 treatments, or services provided within the managed
27 care plan.
28 (6) An explanation of a subscriber's financial
29 responsibility for payment when services are provided by
30 a health care provider who is not part of the managed
31 care plan or by any provider without required
32 authorization or when a procedure, treatment, or service
33 is not a covered health care benefit.
34 (7) A description of the grievance procedures to
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1 be used to resolve disputes between a managed care plan
2 and an enrollee, including the right to file a
3 grievance regarding any dispute between an enrollee and a
4 managed care plan, the right to file a grievance
5 orally when the dispute is about referrals or covered
6 benefits, the toll-free telephone number that enrollees
7 may use to file an oral grievance, the timeframes and
8 circumstances for expedited and standard grievances, the
9 right to appeal a grievance determination and the
10 procedures for filing the appeal, the timeframes and
11 circumstances for expedited and standard appeals, the
12 right to designate a representative, a notice that all
13 disputes involving clinical decisions will be made by
14 qualified clinical personnel, and that all notices of
15 determination will include information about the basis
16 of the decision and further appeal rights, if any.
17 (8) A description of the procedure for providing
18 care and coverage 24 hours a day for emergency services.
19 The description shall include a definition of
20 emergency services, notice that emergency services are
21 not subject to prior approval, and an explanation of
22 the enrollee's financial and other responsibilities
23 regarding obtaining those services including when
24 those services are received outside the managed care
25 plan's service area.
26 (9) A description of procedures for enrollees to
27 select and access the managed care plan's primary and
28 specialty care providers, including notice of how to
29 determine whether a participating provider is accepting
30 new patients.
31 (10) A description of the procedures for changing
32 primary and specialty care providers within the managed
33 care plan.
34 (11) Notice that an enrollee may obtain a referral
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1 to a health care provider outside of the managed care
2 plan's network or panel when the managed care plan
3 does not have a health care provider with appropriate
4 training and experience in the network or panel to meet
5 the particular health care needs of the enrollee and
6 the procedure by which the enrollee can obtain the
7 referral.
8 (12) Notice that an enrollee with a condition
9 that requires ongoing care from a specialist may
10 request a standing referral to the specialist and
11 the procedure for requesting and obtaining a standing
12 referral.
13 (13) Notice that an enrollee with (i) a
14 life-threatening condition or disease or (ii) a
15 degenerative and disabling condition or disease either of
16 which requires specialized medical care over a prolonged
17 period of time may request a specialist responsible for
18 providing or coordinating the enrollee's medical care and
19 the procedure for requesting and obtaining the
20 specialist.
21 (14) Notice that an enrollee with a (i) a
22 life-threatening condition or disease or (ii) a
23 degenerative and disabling condition or disease either of
24 which requires specialized medical care over a prolonged
25 period of time may request access to a specialty care
26 center and the procedure by which access may be
27 obtained.
28 (15) A description of the mechanisms by which
29 enrollees may participate in the development of the
30 policies of the managed care plan.
31 (16) A description of how the managed care plan
32 addresses the needs of non-English speaking enrollees.
33 (17) Notice of all appropriate mailing addresses
34 and telephone numbers to be utilized by enrollees
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1 seeking information or authorization.
2 (18) A listing by specialty, which may be in a
3 separate document that is updated annually, of the name,
4 address, and telephone number of all participating
5 providers, including facilities, and, in addition, in the
6 case of physicians, board certification.
7 (b) Upon request of an enrollee or prospective enrollee,
8 a managed care plan shall do all of the following:
9 (1) Provide a list of the names, business
10 addresses, and official positions of the membership of
11 the board of directors, officers, controlling persons,
12 owners, or partners of the managed care plan.
13 (2) Provide a copy of the most recent annual
14 certified financial statement of the managed care plan,
15 including a balance sheet and summary of receipts and
16 disbursements prepared by a certified public accountant.
17 (3) Provide a copy of the most recent individual,
18 direct pay subscriber contracts.
19 (4) Provide information relating to consumer
20 complaints compiled in the manner set forth in Section
21 143d of the Illinois Insurance Code.
22 (5) Provide the procedures for protecting the
23 confidentiality of medical records and other enrollee
24 information.
25 (6) Allow enrollees and prospective enrollees to
26 inspect drug formularies used by the managed care plan
27 and disclose whether individual drugs are included or
28 excluded from coverage to an enrollee or prospective
29 enrollee who requests this information.
30 (7) Provide a written description of the
31 organizational arrangements and ongoing procedures of
32 the managed care plan's quality assurance program.
33 (8) Provide a description of the procedures
34 followed by the managed care plan in making decisions
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1 about the experimental or investigational nature of
2 individual drugs, medical devices, or treatments in
3 clinical trials.
4 (9) Provide individual health practitioner
5 affiliations with participating hospitals, if any.
6 (10) Upon written request, provide specific
7 written clinical review criteria relating to a
8 particular condition or disease and, where appropriate,
9 other clinical information that the managed care plan
10 might consider in its utilization review; the managed
11 care plan may include with the information a description
12 of how it will be used in the utilization review
13 process, however, to the extent the information is
14 proprietary to the managed care plan, the enrollee or
15 prospective enrollee shall only use the information for
16 the purposes of assisting the enrollee or prospective
17 enrollee in evaluating the covered services provided by
18 the managed care plan.
19 (11) Provide the written application procedures and
20 minimum qualification requirements for health care
21 providers to be considered by the managed care plan.
22 (12) Disclose other information as required by
23 the Director.
24 (c) Nothing in this Section shall prevent a managed care
25 plan from changing or updating the materials that are made
26 available to enrollees.
27 (d) If a primary care provider ceases participation in
28 the managed care plan, the managed care plan shall provide
29 written notice within 15 days from the date that the managed
30 care plan becomes aware of the change in status to each of
31 the enrollees who have chosen the provider as their
32 primary care provider. If an enrollee is in an ongoing
33 course of treatment with any other participating provider who
34 becomes unavailable to continue to provide services to the
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1 enrollee and the managed care plan is aware of the ongoing
2 course of treatment, the managed care plan shall provide
3 written notice within 15 days from the date that the managed
4 care plan becomes aware of the unavailability to the
5 enrollee. Each notice shall also describe the procedures for
6 continuing care.
7 (e) A managed care plan offering to indemnify enrollees
8 for non-participating provider services shall on a quarterly
9 basis file a report with the Director showing the
10 percentage utilization for the preceding quarter of
11 non-participating provider services in such form and
12 providing such other information as the Director shall
13 prescribe.
14 Section 15. Grievance procedure.
15 (a) A managed care plan shall establish and maintain a
16 grievance procedure. Pursuant to such procedure, enrollees
17 shall be entitled to seek a review of determinations by the
18 managed care plan other than determinations made by
19 utilization review agents.
20 (b) A managed care plan shall provide to all enrollees
21 written notice of the grievance procedure in the member
22 handbook and at any time that the managed care plan denies
23 access to a referral or determines that a requested benefit
24 is not covered pursuant to the terms of the contract. In the
25 event that a managed care plan denies a service as an adverse
26 determination, the managed care plan shall inform the
27 enrollee or the enrollee's designee of the appeal rights
28 under this Act.
29 The notice to an enrollee describing the grievance
30 process shall explain the process for filing a grievance
31 with the managed care plan, the timeframes within which a
32 grievance determination must be made, and the right of an
33 enrollee to designate a representative to file a grievance on
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1 behalf of the enrollee.
2 The managed care plan shall assure that the grievance
3 procedure is reasonably accessible to those who do not speak
4 English.
5 (c) The managed care plan may require an enrollee to
6 file a grievance in writing, by letter or by a grievance
7 form which shall be made available by the managed care plan,
8 however, an enrollee may submit an oral grievance in
9 connection with (i) a denial of, or failure to pay for, a
10 referral or (ii) a determination as to whether a benefit is
11 covered pursuant to the terms of the enrollee's contract.
12 In connection with the submission of an oral grievance, a
13 managed care plan may require that the enrollee sign a
14 written acknowledgment of the grievance prepared by the
15 managed care plan summarizing the nature of the grievance.
16 The acknowledgment shall be mailed promptly to the
17 enrollee, who shall sign and return the acknowledgment, with
18 any amendments, in order to initiate the grievance. The
19 grievance acknowledgment shall prominently state that the
20 enrollee must sign and return the acknowledgment to
21 initiate the grievance. If a managed care plan does not
22 require a signed acknowledgment, an oral grievance shall be
23 initiated at the time of the telephone call.
24 Upon receipt of a grievance, the managed care plan shall
25 provide notice specifying what information must be
26 provided to the managed care plan in order to render a
27 decision on the grievance.
28 Except as authorized in this subsection, a managed care
29 plan shall designate personnel to accept the filing of an
30 enrollee's grievance by toll-free telephone no less than
31 40 hours per week during normal business hours and, shall
32 have a telephone system available to take calls during other
33 than normal business hours and shall respond to all such
34 calls no later than the next business day after the call was
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1 recorded. A managed care plan may, in the alternative,
2 designate personnel to accept the filing of an enrollee's
3 grievance by toll-free telephone not less than 40 hours per
4 week during normal business hours and, in the case of
5 grievances subject to item (i) of subsection (d) of this
6 Section, on a 24 hour a day, 7 day a week basis.
7 (d) Within 15 business days of receipt of the
8 grievance, the managed care plan shall provide written
9 acknowledgment of the grievance, including the name,
10 address, and telephone number of the individual or department
11 designated by the managed care plan to respond to the
12 grievance. All grievances shall be resolved in an
13 expeditious manner, and in any event, no more than (i) 48
14 hours after the receipt of all necessary information
15 when a delay would significantly increase the risk to an
16 enrollee's health, (ii) 30 days after the receipt of all
17 necessary information in the case of requests for referrals
18 or determinations concerning whether a requested benefit
19 is covered pursuant to the contract, and (iii) 45 days after
20 the receipt of all necessary information in all other
21 instances.
22 (e) The managed care plan shall designate one or more
23 qualified personnel to review the grievance. When the
24 grievance pertains to clinical matters, the personnel shall
25 include, but not be limited to, one or more licensed,
26 certified, or registered health care professionals.
27 (f) The notice of a determination of the grievance
28 shall be made in writing to the enrollee or to the enrollee's
29 designee. In the case of a determination made in conformance
30 with item (i) of subsection (d) of this Section, notice
31 shall be made by telephone directly to the enrollee with
32 written notice to follow within 3 business days.
33 (g) The notice of a determination shall include (i)
34 the detailed reasons for the determination, (ii) in cases
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1 where the determination has a clinical basis, the
2 clinical rationale for the determination, and (iii) the
3 procedures for the filing of an appeal of the
4 determination, including a form for the filing of an appeal.
5 (h) An enrollee or an enrollee's designee shall
6 have not less than 60 business days after receipt of notice
7 of the grievance determination to file a written appeal,
8 which may be submitted by letter or by a form supplied by the
9 managed care plan.
10 (i) Within 15 business days of receipt of the appeal,
11 the managed care plan shall provide written acknowledgment of
12 the appeal, including the name, address, and telephone number
13 of the individual designated by the managed care plan to
14 respond to the appeal and what additional information, if
15 any, must be provided in order for the managed care plan to
16 render a decision.
17 (j) The determination of an appeal on a clinical matter
18 must be made by personnel qualified to review the appeal,
19 including licensed, certified, or registered health care
20 professionals who did not make the initial
21 determination, at least one of whom must be a clinical
22 peer reviewer. The determination of an appeal on a matter
23 which is not clinical shall be made by qualified personnel at
24 a higher level than the personnel who made the grievance
25 determination.
26 (k) The managed care plan shall seek to resolve all
27 appeals in the most expeditious manner and shall make a
28 determination and provide notice no more than (i) 2
29 business days after the receipt of all necessary information
30 when a delay would significantly increase the risk to an
31 enrollee's health and (ii) 30 business days after the receipt
32 of all necessary information in all other instances.
33 (l) The notice of a determination on an appeal shall
34 include (i) the detailed reasons for the determination and
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1 (ii) in cases where the determination has a clinical
2 basis, the clinical rationale for the determination.
3 (m) A managed care plan shall not retaliate or take
4 any discriminatory action against an enrollee because an
5 enrollee has filed a grievance or appeal.
6 (n) A managed care plan shall maintain a file on each
7 grievance and associated appeal, if any, that shall
8 include the date the grievance was filed, a copy of the
9 grievance, if any, the date of receipt of and a copy of
10 the enrollee's acknowledgment of the grievance, if any,
11 the determination made by the managed care plan including the
12 date of the determination and the titles and, in the case
13 of a clinical determination, the credentials of the managed
14 care plan's personnel who reviewed the grievance. If an
15 enrollee files an appeal of the grievance, the file shall
16 include the date and a copy of the enrollee's appeal, the
17 determination made by the managed care plan including the
18 date of the determination and the titles and, in the case of
19 clinical determinations, the credentials, of the managed care
20 plan's personnel who reviewed the appeal.
21 (o) The rights and remedies conferred in this Section
22 upon enrollees are cumulative and in addition to and not
23 in lieu of any other rights or remedies available under law.
24 Section 20. External independent review.
25 (a) If an enrollee's request for a covered service or
26 claim for a covered service is denied under Section 15, the
27 enrollee may initiate an external independent review.
28 (b) Within 30 days after the enrollee receives written
29 notice of the adverse decision made pursuant to Section 15,
30 if the enrollee decides to initiate an external independent
31 review, the enrollee shall send to the managed care plan a
32 written request for an external independent review, including
33 any material justification or documentation to support the
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1 enrollee's request for the covered service or claim for a
2 covered service.
3 (c) Within 5 business days after the managed care plan
4 receives a request for an external independent review from
5 the enrollee, the managed care plan shall:
6 (1) For cases involving an issue of medical
7 necessity, do all of the following:
8 (A) Send a written acknowledgment to the
9 Director, the enrollee, and the enrollee's treating
10 provider.
11 (B) Choose one or more independent reviewers
12 in the manner prescribed in subsections (h) and (i)
13 of this Section from the list established by the
14 Director pursuant to Section 25 and forward that
15 choice to the Director.
16 (C) Include in the written acknowledgment to
17 the Director, the choice made pursuant to
18 subdivision (B) of this paragraph.
19 (2) For cases involving only an issue of coverage,
20 do all of the following:
21 (A) Send a written acknowledgment to the
22 Director, the enrollee, and the enrollee's treating
23 provider.
24 (B) Forward to the Director the terms of
25 agreement in the enrollee's policy, evidence of
26 coverage, or similar document and all relevant
27 medical records and supporting documentation used to
28 render the decision pertaining to the enrollee's
29 case, a summary description of the applicable issues
30 including a statement of the managed care plan's
31 decision, and the criteria used and the clinical
32 reasons for that decision.
33 (d) Within 30 days after the managed care plan receives
34 the written request for an independent review by the enrollee
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1 and if:
2 (1) The case involves an issue of medical
3 necessity, the managed care plan shall:
4 (A) Forward to the independent reviewer or
5 reviewers all medical records and supporting
6 documentation pertaining to the case, a summary
7 description of the applicable issues including a
8 statement of the managed care plan's, decision, and
9 the criteria used and the clinical reasons for that
10 decision.
11 (B) Notify the Director, the enrollee, and the
12 enrollee's treating provider of the decision by the
13 independent reviewer or reviewers.
14 (2) The case involves only an issue of coverage,
15 the plan shall notify the enrollee and the enrollee's
16 treating provider of the decision.
17 (e) For cases involving medical necessity, the
18 independent reviewer or reviewers shall evaluate and analyze
19 the case and render a decision that is based on whether or
20 not the service or claim for the service is medically
21 necessary. The decision by the independent reviewer or
22 reviewers is a final decision under the Administrative Review
23 Law and is subject to review under the Administrative Review
24 Law. The managed care plan shall provide any service
25 determined to be medically necessary by the independent
26 reviewer or reviewers for the case under review regardless of
27 whether judicial review is sought.
28 (f) For cases involving an issue of coverage, within 5
29 business days after receipt of the case, the Director shall
30 determine if the service or claim is or is not covered, and
31 the Director shall determine if the adverse decision made
32 pursuant to Section 15 conforms to this Article and shall
33 notify the managed care plan of the determination. If the
34 Director is unable to determine issues of coverage, the
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1 Director shall submit the case to external independent review
2 in accordance with subsections (c), (d), and (e) of this
3 Section.
4 (g) After a decision is made pursuant to subsection (e)
5 or (f) of this Section, the reconsideration, appeal, and
6 administrative processes are completed.
7 (h) Pursuant to subsection (c) of this Section, the
8 managed care plan shall choose one or more independent
9 reviewers or organizations that represent independent
10 reviewers who:
11 (1) Have no direct financial interest in or
12 connection to the case.
13 (2) Are licensed as physicians, who are board
14 certified or board eligible by the appropriate American
15 Medical Specialty Board and who are in the same or
16 similar scope of practice as a physician who typically
17 manages the medical condition, procedure, or treatment
18 under review.
19 (3) Have not been informed of the specific
20 identities of the enrollee or the enrollee's treating
21 provider.
22 (i) If an appropriate reviewer pursuant to subsection
23 (h) of this Section for a particular case is not on the list
24 established by the Director, the parties shall choose a
25 reviewer who is mutually acceptable.
26 Section 25. Independent reviewers.
27 (a) From information filed with the Director on or
28 before March 1 of each year, the Director shall compile a
29 list of independent reviewers and organizations that
30 represent independent reviewers from lists provided by health
31 care insurers and by any State and county health and medical
32 associations that wish to submit a list the the Director.
33 The Director may consult with other persons about the
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1 suitability of any reviewer or any potential reviewer. The
2 Director shall annually review the list and add and remove
3 names as appropriate. On or before June 1 of each year, the
4 Director shall publish the list in the Illinois register.
5 (b) An out of State provider who is licensed in another
6 state and who is not licensed in this State may serve as
7 independent reviewer, and that provider's analysis,
8 assessment, or decision as an independent reviewer does not
9 constitute the practice of medicine in this State.
10 (c) The managed care plan shall be solely responsible
11 for paying the fees of the independent reviewer who was
12 selected to perform the review.
13 (d) The Director or any independent reviewer acting in
14 good faith is not liable for the analysis, assessment, or
15 decision of any case reviewed pursuant to this Act.
16 (e) The Director's decision to add any name to or remove
17 any name from the list of independent reviewers pursuant to
18 subsection (a) is not subject to administrative appeal or
19 judicial review.
20 Section 30. Health care professional applications and
21 terminations.
22 (a) A managed care plan shall, upon request, make
23 available and disclose to health care professionals written
24 application procedures and minimum qualification
25 requirements that a health care professional must meet in
26 order to be considered by the managed care plan. The
27 managed care plan shall consult with appropriately qualified
28 health care professionals in developing its qualification
29 requirements.
30 (b) A managed care plan shall not terminate a contract
31 with a health care professional unless the managed care plan
32 provides to the health care professional a written
33 explanation of the reasons for the proposed contract
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1 termination and an opportunity for a review or hearing as
2 hereinafter provided. This Section shall not apply in cases
3 involving imminent harm to patient care, a determination of
4 fraud, or a final disciplinary action by a state
5 licensing board or other governmental agency that impairs the
6 health care professional's ability to practice.
7 The notice of the proposed contract termination provided
8 by the managed care plan to the health care professional
9 shall include:
10 (1) the reasons for the proposed action;
11 (2) notice that the health care professional has the
12 right to request a hearing or review, at the
13 professional's discretion, before a panel appointed by
14 the managed care plan;
15 (3) a time limit of not less than 30 days within
16 which a health care professional may request a hearing;
17 and
18 (4) a time limit for a hearing date which must be
19 held within 30 days after the date of receipt of a
20 request for a hearing.
21 The hearing panel shall be comprised of 3 persons
22 appointed by the health care plan. At least one person on the
23 panel shall be a clinical peer in the same discipline and the
24 same or similar specialty as the health care professional
25 under review. The hearing panel may consist of more than 3
26 persons, however, the number of clinical peers on the
27 panel shall constitute one-third or more of the total
28 membership of the panel.
29 The hearing panel shall render a decision on the
30 proposed action in a timely manner. The decision shall
31 include reinstatement of the health care professional by the
32 health care plan, provisional reinstatement subject to
33 conditions set forth by the health care plan or termination
34 of the health care professional. The decision shall be
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1 provided in writing to the health care professional.
2 A decision by the hearing panel to terminate a health
3 care professional shall be effective not less than 30 days
4 after the receipt by the health care professional of the
5 hearing panel's decision.
6 A statement of reasons for proposed action furnished in
7 accordance with the provisions of this Section shall be
8 deemed a confidential communication and shall not be
9 subject to inspection or disclosure in any manner except
10 upon formal written request by a duly authorized public
11 agency or pursuant to a judicial subpoena issued in a
12 pending action or proceeding.
13 Any person, facility, organization, or corporation that
14 makes a statement of reasons for proposed action pursuant to
15 this Section in good faith without malice shall have immunity
16 from any liability, civil or criminal, for having made the
17 report. For purposes of any proceeding, civil or criminal,
18 the good faith of any person required to make a report shall
19 be presumed.
20 (c) Upon 60 days notice to the other party, either party
21 to a contract may exercise a right of non-renewal at the
22 expiration of the contract period set forth therein or,
23 for a contract without a specific expiration date, on
24 each January 1 occurring after the contract has been in
25 effect for at least one year; provided, however, that any
26 non-renewal shall not constitute a termination for
27 purposes of this Section.
28 (d) A managed care plan shall develop and implement
29 policies and procedures to ensure that health care
30 professionals are regularly informed of information
31 maintained by the managed care plan to evaluate the
32 performance or practice of the health care professional. The
33 managed care plan shall consult with health care
34 professionals in developing methodologies to collect and
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1 analyze health care professional profiling data. Managed
2 care plans shall provide any the information and profiling
3 data and analysis to health care professionals. The
4 information, data, or analysis shall be provided on a
5 periodic basis appropriate to the nature and amount of data
6 and the volume and scope of services provided. Any
7 profiling data used to evaluate the performance or practice
8 of a health care professional shall be measured against
9 stated criteria and an appropriate group of health care
10 professionals using similar treatment modalities serving a
11 comparable patient population. Upon presentation of the
12 information or data, each health care professional shall be
13 given the opportunity to discuss the unique nature of the
14 health care professional's patient population that may have a
15 bearing on the health care professional's profile and to
16 work cooperatively with the managed care plan to improve
17 performance.
18 (e) A managed care plan may not terminate a contract or
19 employment, or refuse to renew a contract, solely because a
20 health care provider has:
21 (1) advocated on behalf of an enrollee;
22 (2) filed a complaint against the managed care
23 plan;
24 (3) appealed a decision of the managed care plan;
25 or
26 (4) requested a hearing or review pursuant to this
27 Section.
28 (f) Except as provided herein, no contract or
29 agreement between a managed care plan and a health care
30 professional shall contain any provision that supersedes or
31 impairs a health care professional's right to notice of
32 reasons for termination and the opportunity for a hearing or
33 review concerning termination.
34 (g) Any contract provision in violation of this Section
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1 is void and unenforceable.
2 Section 35. Prohibitions.
3 (a) No managed care plan shall by contract, written
4 policy or written procedure, or informal policy or procedure
5 prohibit or restrict any health care provider from
6 disclosing to any subscriber, enrollee, patient,
7 designated representative or, where appropriate,
8 prospective enrollee, (hereinafter collectively referred
9 to as enrollee) any information that the provider deems
10 appropriate regarding:
11 (1) a condition or a course of treatment with an
12 enrollee including the availability of other therapies,
13 consultations, or tests; or
14 (2) the provisions, terms, or requirements of the
15 managed care plan's products as they relate to the
16 enrollee, where applicable.
17 (b) No managed care plan shall by contract, written
18 policy or procedure, or informal policy or procedure prohibit
19 or restrict any health care provider from filing a
20 complaint, making a report, or commenting to an appropriate
21 governmental body regarding the policies or practices of the
22 managed care plan organization that the provider believes
23 may negatively impact upon the quality of, or access to,
24 patient care.
25 (c) No managed care plan shall by contract, written
26 policy or procedure, or informal policy or procedure prohibit
27 or restrict any health care provider from advocating to the
28 managed care plan on behalf of the enrollee for approval or
29 coverage of a particular course of treatment or for the
30 provision of health care services.
31 (d) No contract or agreement between a managed care
32 plan and a health care provider shall contain any clause
33 purporting to transfer to the health care provider,
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1 other than a medical group, by indemnification or otherwise
2 any liability relating to activities, actions, or omissions
3 of the managed care plan as opposed to those of the health
4 care provider.
5 (e) A managed care plan may not deny coverage for
6 treatment authorized after a consultation by a health care
7 provider affiliated with the plan.
8 (f) Any contract provision, written policy or
9 procedure, or informal policy or procedure in violation of
10 this Section is void and unenforceable.
11 Section 40. Network of providers.
12 (a) At least once every 3 years, and upon application
13 for expansion of service area, a managed care plan shall
14 obtain certification from the Director that the managed care
15 plan maintains a network of health care providers adequate
16 to meet the comprehensive health needs of its enrollees and
17 to provide an appropriate choice of providers sufficient to
18 provide the services covered under its enrollee's contracts
19 by determining that:
20 (1) there are a sufficient number of
21 geographically accessible participating providers;
22 (2) there are opportunities to select from at least
23 3 primary care providers pursuant to travel and
24 distance time standards, providing that these standards
25 account for the conditions of accessing providers in
26 rural areas;
27 (3) there are sufficient providers in each area of
28 specialty practice to meet the needs of the enrollment
29 population; and
30 (4) there is no exclusion of any appropriately
31 licensed type of provider as a class.
32 (b) The following criteria shall be considered by the
33 Director at the time of a review:
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1 (1) the availability of appropriate and timely care
2 that is provided in compliance with the standards of
3 the federal Americans with Disabilities Act to assure
4 access to health care for the enrollee population;
5 (2) the network's ability to provide culturally
6 and linguistically competent care to meet the needs
7 of the enrollee population; and
8 (3) the number of grievances filed by enrollees
9 relating to waiting times for appointments,
10 appropriateness of referrals, and other indicators of
11 managed care plan's capacity.
12 (c) A managed care plan shall report on an annual basis
13 the number of enrollees and the number of participating
14 providers in the managed care plan.
15 (d) If a managed plan determines that it does not have a
16 health care provider with appropriate training and experience
17 in its panel or network to meet the particular health care
18 needs of an enrollee, the managed care plan shall make a
19 referral to an appropriate provider, pursuant to a treatment
20 plan approved by the managed care plan in consultation
21 with the primary care provider, the non-participating
22 provider, and the enrollee or enrollee's designee, at no
23 additional cost to the enrollee beyond what the enrollee
24 would otherwise pay for services received within the network.
25 (e) A managed care plan shall have a procedure by which
26 an enrollee who needs ongoing care from a specialist may
27 receive a standing referral to the specialist. If the
28 managed care plan, or the primary care provider in
29 consultation with the medical director of the managed care
30 plan and specialist if any, determines that a standing
31 referral is appropriate, the managed care plan shall make
32 such a referral to a specialist. In no event shall a managed
33 care plan be required to permit an enrollee to elect to
34 have a non-participating specialist, except pursuant to the
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1 provisions of subsection (d). The referral shall be pursuant
2 to a treatment plan approved by the managed care plan in
3 consultation with the primary care provider, the specialist,
4 and the enrollee or the enrollee's designee. The treatment
5 plan may limit the number of visits or the period during
6 which visits are authorized and may require the specialist to
7 provide the primary care provider with regular updates on the
8 specialty care provided, as well as all necessary medical
9 information.
10 (f) A managed care plan shall have a procedure by which
11 a new enrollee, upon enrollment, or an enrollee, upon
12 diagnosis, with (i) a life-threatening condition or disease,
13 or (ii) a degenerative and disabling condition or disease,
14 either of which requires specialized medical care over a
15 prolonged period of time, may receive a referral to a
16 specialist with expertise in treating the life-threatening or
17 degenerative and disabling disease or condition who shall be
18 responsible for and capable of providing and coordinating
19 the enrollee's primary and specialty care. If the managed
20 care plan, or primary care provider in consultation with a
21 medical director of the managed care plan and a specialist,
22 if any, determines that the enrollee's care would most
23 appropriately be coordinated by such a specialist, the
24 managed care plan shall refer the enrollee to such
25 specialist. In no event shall a managed care plan be required
26 to permit an enrollee to elect to have a non-participating
27 specialist, except pursuant to the provisions of subsection
28 (d). The referral shall be pursuant to a treatment plan
29 approved by the managed care plan, in consultation with the
30 primary care provider if appropriate, the specialist, and the
31 enrollee or the enrollee's designee. The specialist shall be
32 permitted to treat the enrollee without a referral
33 from the enrollee's primary care provider and may
34 authorize such referrals, procedures, tests, and other
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1 medical services as the enrollee's primary care provider
2 would otherwise be permitted to provide or authorize,
3 subject to the terms of the treatment plan. If a managed care
4 plan refers an enrollee to a non-participating provider,
5 services provided pursuant to the approved treatment plan
6 shall be provided at no additional cost to the enrollee
7 beyond what the enrollee would otherwise pay for services
8 received within the network.
9 (g) A managed care plan shall have a procedure by which
10 an enrollee with (i) a life-threatening condition or
11 disease or (ii) a degenerative and disabling condition or
12 disease, either of which requires specialized medical
13 care over a prolonged period of time, may receive a referral
14 to a specialty care center with expertise in treating the
15 life-threatening or degenerative and disabling disease or
16 condition. If the managed care plan, or the primary care
17 provider or the specialist designated pursuant to subsection
18 (f), in consultation with a medical director of the managed
19 care plan, determines that the enrollee's care would most
20 appropriately be provided by a specialty care center, the
21 managed care plan shall refer the enrollee to a specialty
22 care center. In no event shall a managed care plan be
23 required to permit an enrollee to elect to have a
24 non-participating specialty care center, unless the
25 managed care plan does not have an appropriate specialty
26 care center to treat the enrollee's disease or condition
27 within its network. The referral shall be pursuant to a
28 treatment plan developed by the specialty care center and
29 approved by the managed care plan, in consultation with the
30 primary care provider, if any, or a specialist designated
31 pursuant to subsection (f), and the enrollee or the
32 enrollee's designee. If a managed care plan refers an
33 enrollee to a specialty care center that does not participate
34 in the managed care plan's network, services provided
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1 pursuant to the approved treatment plan shall be provided
2 at no additional cost to the enrollee beyond what the
3 enrollee would otherwise pay for services received
4 within the network. For purposes of this subsection, a
5 specialty care center shall mean only those centers that are
6 accredited or designated by an agency of the state or
7 federal government or by a voluntary national health
8 organization as having special expertise in treating the
9 life-threatening disease or condition or degenerative and
10 disabling disease or condition for which it is accredited or
11 designated.
12 (h) If an enrollee's health care provider leaves the
13 managed care plan's network of providers for reasons other
14 than those for which the provider would not be eligible to
15 receive a hearing pursuant to subsection (b) of Section 30,
16 the managed care plan shall permit the enrollee to continue
17 an ongoing course of treatment with the enrollee's
18 current health care provider during a transitional period of:
19 (1) up to 90 days from the date of notice to the
20 enrollee of the provider's disaffiliation from the
21 managed care plan's network; or
22 (2) if the enrollee has entered the second trimester
23 of pregnancy at the time of the provider's
24 disaffiliation, for a transitional period that
25 includes the provision of post-partum care directly
26 related to the delivery.
27 Transitional care, however, shall be authorized by the
28 managed care plan during the transitional period only if the
29 health care provider agrees (i) to continue to accept
30 reimbursement from the managed care plan at the rates
31 applicable prior to the start of the transitional period
32 as payment in full, (ii) to adhere to the managed care plan's
33 quality assurance requirements and to provide to the managed
34 care plan necessary medical information related to the care,
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1 and (iii) to otherwise adhere to the managed care plan's
2 policies and procedures, including but not limited to
3 procedures regarding referrals and obtaining
4 pre-authorization and a treatment plan approved by the
5 managed care plan.
6 (i) If a new enrollee whose health care provider is not
7 a member of the managed care plan's provider network enrolls
8 in the managed care plan, the managed care plan shall permit
9 the enrollee to continue an ongoing course of treatment with
10 the enrollee's current health care provider during a
11 transitional period of up to 60 days from the effective
12 date of enrollment, if (i) the enrollee has a
13 life-threatening disease or condition or a degenerative and
14 disabling disease or condition or (ii) the enrollee has
15 entered the second trimester of pregnancy at the effective
16 date of enrollment, in which case the transitional period
17 shall include the provision of post-partum care directly
18 related to the delivery. If an enrollee elects to continue
19 to receive care from a health care provider pursuant to this
20 subsection, the care shall be authorized by the managed care
21 plan for the transitional period only if the health care
22 provider agrees (i) to accept reimbursement from the managed
23 care plan at rates established by the managed care plan as
24 payment in full, which rates shall be no more than the level
25 of reimbursement applicable to similar providers within
26 the managed care plan's network for those services, (ii)
27 to adhere to the managed care plan's quality assurance
28 requirements and agrees to provide to the managed care plan
29 necessary medical information related to the care, and
30 (iii) to otherwise adhere to the managed care plan's policies
31 and procedures including, but not limited to, procedures
32 regarding referrals and obtaining pre-authorization and a
33 treatment plan approved by the managed care plan. In no
34 event shall this subsection be construed to require a managed
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1 care plan to provide coverage for benefits not otherwise
2 covered or to diminish or impair pre-existing condition
3 limitations contained within the subscriber's contract.
4 Section 45. Duty to report.
5 (a) A managed care plan shall make a report to the
6 appropriate professional disciplinary agency within 30 days
7 of the occurrence of any of the following:
8 (1) the termination of a health care provider
9 contract pursuant to Section 30 for reasons relating to
10 alleged mental or physical impairment, misconduct, or
11 impairment of patient safety or welfare;
12 (2) the voluntary or involuntary termination of a
13 contract or employment or other affiliation with the
14 managed care plan to avoid the imposition of disciplinary
15 measures; or
16 (3) the termination of a health care provider
17 contract in the case of a determination of fraud or in a
18 case of imminent harm to patient health.
19 (b) A managed care plan shall make a report to be made
20 to the appropriate professional disciplinary agency within 60
21 days of obtaining knowledge of any information that
22 reasonably appears to show that a health professional is
23 guilty of professional misconduct.
24 (c) Reports of possible professional misconduct made
25 pursuant to this Section shall be made in writing to the
26 appropriate professional disciplinary agency. Written
27 reports shall include the name, address, profession, and
28 license number of the individual and a description of the
29 action taken by the managed care plan, including the reason
30 for the action and the date thereof, or the nature of the
31 action or conduct that led to the resignation, termination of
32 contract, or withdrawal, and the date thereof.
33 (d) Any report or information furnished to an
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1 appropriate professional discipline agency in accordance
2 with the provisions of this Section shall be deemed a
3 confidential communication and shall not be subject to
4 inspection or disclosure in any manner except upon formal
5 written request by a duly authorized public agency or
6 pursuant to a judicial subpoena issued in a pending action
7 or proceeding.
8 (e) Any person, facility, organization, or corporation
9 that makes a report pursuant to this Section in good faith
10 without malice shall have immunity from any liability,
11 civil or criminal, for having made the report. For purposes
12 of any proceeding, civil or criminal, the good faith of
13 any person required to make a report shall be presumed.
14 Section 50. Disclosure of information.
15 (a) A health care professional affiliated with a
16 managed care plan shall, upon request, provide to his or her
17 patient or prospective patient the following:
18 (1) information related to the health care
19 professional's educational background, experience,
20 training, specialty, and board certification, if
21 applicable;
22 (2) information regarding the health care
23 professional's participation in continuing education
24 programs and compliance with any licensure,
25 certification, or registration requirements, if
26 applicable; and
27 (3) information regarding the health care
28 professional's participation in clinical performance
29 reviews conducted by the department where applicable and
30 where available.
31 (b) Nothing contained in this Section shall require
32 written disclosure of the information described in
33 subsection (a) by the health care professional to the
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1 patient.
2 Section 55. Registration of utilization review agents.
3 (a) A utilization review agent who conducts the practice
4 of utilization review shall biennially register with the
5 Director and report, in a statement subscribed and affirmed
6 as true under the penalties of perjury, the information
7 required pursuant to subsection (b) of this Section.
8 (b) The report shall contain a description of the
9 following:
10 (1) the utilization review plan;
11 (2) the provisions by which an enrollee, the
12 enrollee's designee, or a health care provider may seek
13 reconsideration of, or appeal from, adverse
14 determinations by the utilization review agent, in
15 accordance with the provisions of this Act, including
16 provisions to ensure a timely appeal and that an
17 enrollee, the enrollee's designee, and, in the case of
18 an adverse determination involving a retrospective
19 determination, the enrollee's health care provider, is
20 informed of their right to appeal adverse determinations;
21 (3) procedures by which a decision on a request for
22 utilization review for services requiring
23 preauthorization shall comply with timeframes
24 established pursuant to this Act;
25 (4) a description of an emergency care policy,
26 which shall include the procedures under which an
27 emergency admission shall be made or emergency treatment
28 shall be given;
29 (5) a description of the personnel utilized to
30 conduct utilization review including a description of
31 the circumstances under which utilization review may be
32 conducted by:
33 (A) administrative personnel,
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1 (B) health care professionals who are not
2 clinical peer reviewers, and
3 (C) clinical peer reviewers;
4 (6) a description of the mechanisms employed to
5 assure that administrative personnel are trained in the
6 principles and procedures of intake screening and data
7 collection and are appropriately monitored by a
8 licensed health care professional while performing an
9 administrative review;
10 (7) a description of the mechanisms employed to
11 assure that health care professionals conducting
12 utilization review are:
13 (A) appropriately licensed, registered, or
14 certified and
15 (B) trained in the principles, procedures,
16 and standards of the utilization review agent;
17 (8) a description of the mechanisms employed to
18 assure that only a clinical peer reviewer shall render an
19 adverse determination;
20 (9) provisions to ensure that appropriate personnel
21 of the utilization review agent are reasonably accessible
22 by toll-free telephone:
23 (A) not less than 40 hours per week during
24 normal business hours, to discuss patient care and
25 allow response to telephone requests, and to ensure
26 that the utilization review agent has a telephone
27 system capable of accepting, recording, or providing
28 instruction to incoming telephone calls during
29 other than normal business hours and to ensure
30 response to accepted or recorded messages not later
31 than the next business day after the date on which
32 the call was received; or
33 (B) notwithstanding the provisions of item (1),
34 not less than 40 hours per week during normal
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1 business hours, to discuss patient care and allow
2 response to telephone requests, and to ensure that,
3 in the case of a request submitted pursuant to
4 subsection (c) of Section 65 or an expedited appeal
5 filed pursuant to subsection (b) of Section 70, 24
6 hour a day, 7 day a week basis;
7 (10) the policies and procedures to ensure that
8 all applicable State and federal laws to protect the
9 confidentiality of individual medical and treatment
10 records are followed;
11 (11) a copy of the materials to be disclosed to an
12 enrollee or prospective enrollee pursuant to this Act;
13 (12) a description of the mechanisms employed by
14 the utilization review agent to assure that all
15 contractors, subcontractors, subvendors, agents, and
16 employees affiliated by contract or otherwise with such
17 utilization review agent will adhere to the standards and
18 requirements of this Act; and
19 (13) a list of the payors for which the
20 utilization review agent is performing utilization
21 review in this State.
22 (c) Upon receipt of the report, the Director
23 shall issue an acknowledgment of the filing.
24 (d) A registration issued under this Act shall be valid
25 for a period of not more than 2 years, and may be renewed for
26 additional periods of not more than 2 years each.
27 Section 60. Utilization review program standards.
28 (a) A utilization review agent shall adhere to
29 utilization review program standards consistent with the
30 provisions of this Act which shall, at a minimum, include:
31 (1) appointment of a medical director, who is a
32 licensed physician; provided, however, that the
33 utilization review agent may appoint a clinical director
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1 when the utilization review performed is for a discrete
2 category of health care service and provided further that
3 the clinical director is a licensed health care
4 professional who typically manages the category of
5 service; responsibilities of the medical director, or,
6 where appropriate, the clinical director, shall
7 include, but not be limited to, the supervision and
8 oversight of the utilization review process;
9 (2) development of written policies and procedures
10 that govern all aspects of the utilization review
11 process and a requirement that a utilization review
12 agent shall maintain and make available to enrollees and
13 health care providers a written description of the
14 procedures including procedures to appeal an adverse
15 determination;
16 (3) utilization of written clinical review criteria
17 developed pursuant to a utilization review plan;
18 (4) establishment of a process for rendering
19 utilization review determinations which shall, at a
20 minimum, include written procedures to assure that
21 utilization reviews and determinations are conducted
22 within the timeframes established herein, procedures to
23 notify an enrollee, an enrollee's designee, and an
24 enrollee's health care provider of adverse
25 determinations, and procedures for appeal of adverse
26 determinations, including the establishment of an
27 expedited appeals process for denials of continued
28 inpatient care or where there is imminent or serious
29 threat to the health of the enrollee;
30 (5) establishment of a written procedure to assure
31 that the notice of an adverse determination includes:
32 (A) the reasons for the determination including
33 the clinical rationale, if any;
34 (B) instructions on how to initiate an
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1 appeal; and
2 (C) notice of the availability of the
3 clinical review criteria relied upon to make the
4 determination;
5 (6) establishment of a requirement that
6 appropriate personnel of the utilization review agent are
7 reasonably accessible 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 such 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 less
16 than one business day after the date on which the
17 call was received; or
18 (B) notwithstanding the provisions of item
19 (A), 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 65 or an expedited
24 appeal filed pursuant to subsection (b) of
25 Section 70, on a 24 hour a day, 7 day a week basis;
26 (7) establishment of appropriate policies and
27 procedures to ensure that all applicable State and
28 federal laws to protect the confidentiality of individual
29 medical records are followed;
30 (8) establishment of a requirement that emergency
31 services rendered to an enrollee shall not be subject
32 to prior authorization nor shall reimbursement for
33 those services be denied on retrospective review;
34 provided, however, that those services are medically
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1 necessary to stabilize or treat an emergency condition.
2 (b) A utilization review agent shall assure adherence to
3 the requirements stated in subsection (a) of this Section by
4 all contractors, subcontractors, subvendors, agents, and
5 employees affiliated by contract or otherwise with the
6 utilization review agent.
7 Section 65. Utilization review determinations.
8 (a) Utilization review shall be conducted by:
9 (1) administrative personnel trained in the
10 principles and procedures of intake screening and data
11 collection, provided, however, that administrative
12 personnel shall only perform intake screening, data
13 collection, and non-clinical review functions and shall
14 be supervised by a licensed health care professional;
15 (2) a health care professional who is
16 appropriately trained in the principles, procedures,
17 and standards of such utilization review agent; provided,
18 however, that a health care professional who is not a
19 clinical peer reviewer may not render an adverse
20 determination; and
21 (3) a clinical peer reviewer where the review
22 involves an adverse determination.
23 (b) A utilization review agent shall make a utilization
24 review determination involving health care services that
25 require pre-authorization and provide notice of a
26 determination to the enrollee or enrollee's designee
27 and the enrollee's health care provider by telephone and
28 in writing within 3 business days of receipt of the necessary
29 information.
30 (c) A utilization review agent shall make a
31 determination involving continued or extended health care
32 services, or additional services for an enrollee
33 undergoing a course of continued treatment prescribed by a
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1 health care provider and provide notice of the determination
2 to the enrollee or the enrollee's designee, which may be
3 satisfied by notice to the enrollee's health care provider,
4 by telephone and in writing within one business day of
5 receipt of the necessary information. Notification of
6 continued or extended services shall include the number of
7 extended services approved, the new total of approved
8 services, the date of onset of services, and the next review
9 date.
10 (d) A utilization review agent shall make a utilization
11 review determination involving health care services that have
12 been delivered within 30 days of receipt of the necessary
13 information.
14 (e) Notice of an adverse determination made by a
15 utilization review agent shall be in writing and must
16 include:
17 (1) the reasons for the determination including the
18 clinical rationale, if any;
19 (2) instructions on how to initiate an appeal; and
20 (3) notice of the availability of the clinical
21 review criteria relied upon to make the determination;
22 the notice shall also specify what, if any, additional
23 necessary information must be provided to, or obtained
24 by, the utilization review agent in order to render a
25 decision on the appeal.
26 (f) In the event that a utilization review agent
27 renders an adverse determination without attempting to
28 discuss the matter with the enrollee's health care
29 provider who specifically recommended the health care
30 service, procedure, or treatment under review, the health
31 care provider shall have the opportunity to request a
32 reconsideration of the adverse determination. Except in
33 cases of retrospective reviews, the reconsideration shall
34 occur within one business day of receipt of the request
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1 and shall be conducted by the enrollee's health care
2 provider and the clinical peer reviewer making the initial
3 determination or a designated clinical peer reviewer if the
4 original clinical peer reviewer cannot be available. In
5 the event that the adverse determination is upheld after
6 reconsideration, the utilization review agent shall provide
7 notice as required pursuant to subsection (e) of this
8 Section. Nothing in this Section shall preclude the enrollee
9 from initiating an appeal from an adverse determination.
10 Section 70. Appeal of adverse determinations by
11 utilization review agents.
12 (a) An enrollee, the enrollee's designee and, in
13 connection with retrospective adverse determinations, an
14 enrollee's health care provider, may appeal an adverse
15 determination rendered by a utilization review agent.
16 (b) A utilization review agent shall establish an
17 expedited appeal process for appeal of an adverse
18 determination involving:
19 (1) continued or extended health care services,
20 procedures, or treatments or additional services for an
21 enrollee undergoing a course of continued treatment
22 prescribed by a health care provider; or
23 (2) an adverse determination in which the
24 health care provider believes an immediate appeal is
25 warranted except any retrospective determination.
26 The appeal process shall include mechanisms that
27 facilitate resolution of the appeal including, but not
28 limited to, the sharing of information from the
29 enrollee's health care provider and the utilization review
30 agent by telephonic means or by facsimile. The utilization
31 review agent shall provide reasonable access to its
32 clinical peer reviewer within one business day of receiving
33 notice of the taking of an expedited appeal. Expedited
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1 appeals must be determined within 2 business days of receipt
2 of necessary information to conduct the appeal. Expedited
3 appeals that do not result in a resolution satisfactory to
4 the appealing party may be further appealed through the
5 standard appeal process.
6 (c) A utilization review agent shall establish a
7 standard appeal process that includes procedures for appeals
8 to be filed in writing or by telephone. A utilization
9 review agent must establish a period of no less than 45 days
10 after receipt of notification by the enrollee of the initial
11 utilization review determination and receipt of all
12 necessary information to file the appeal from the
13 determination. The utilization review agent must provide
14 written acknowledgment of the filing of the appeal to the
15 appealing party within 15 days of the filing and shall make a
16 determination with regard to the appeal within 60 days of
17 the receipt of necessary information to conduct the
18 appeal. The utilization review agent shall notify the
19 enrollee, the enrollee's designee and, where appropriate,
20 the enrollee's health care provider, in writing, of the
21 appeal determination within 2 business days of the rendering
22 of the determination. The notice of the appeal determination
23 shall include the reasons for the determination; provided,
24 however, that where the adverse determination is upheld on
25 appeal, the notice shall include the clinical rationale
26 for the determination.
27 (d) Both expedited and standard appeals shall be
28 reviewed by a clinical peer reviewer other than the
29 clinical peer reviewer who rendered the adverse
30 determination.
31 Section 75. Required and prohibited practices.
32 (a) A utilization review agent shall have written
33 procedures for assuring that patient-specific information
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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
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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
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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
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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 Section 80. Waiver. Any agreement that purports to
15 waive, limit, disclaim or in any way diminish the rights set
16 forth in this Act is void as contrary to public policy.
17 Section 85. Rights and remedies. The rights and remedies
18 conferred in this Act upon enrollees and health care
19 providers are cumulative and in addition to and not in lieu
20 of any other rights or remedies available under law.
21 Section 90. Administration of Act. The Department of
22 Public Health shall administer this Act and may promulgate
23 rules for that purpose.
24 Section 95. Civil penalty; other relief.
25 (a) If the Attorney General determines that violation of
26 this Act has occurred, the Attorney General may bring an
27 action in the circuit court of the county in which the
28 violation occurred to recover a civil penalty of no more than
29 $5,000 for each violation. Each day that a violation
30 continues constitutes a separate violation. In addition, the
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1 Attorney General may petition for an order enjoining the
2 violation of this Act.
3 (b) The Attorney General may promulgate reasonable and
4 necessary rules to carry out the purposes of this Section.".