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91_HB2185
LRB9104309JSmg
1 AN ACT to amend the Health Maintenance Organization Act
2 by changing Section 4-10.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Health Maintenance Organization Act is
6 amended by changing Section 4-10 as follows:
7 (215 ILCS 125/4-10) (from Ch. 111 1/2, par. 1409.3)
8 Sec. 4-10. (a) Medical necessity; dispute
9 resolution-independent second opinion. A Each Health
10 Maintenance Organization shall provide a mechanism for the
11 timely review by a physician holding the same class of
12 license as the primary care physician, who is unaffiliated
13 with the Health Maintenance Organization, jointly selected by
14 the patient (or the patient's next of kin or legal
15 representative if the patient is unable to act for himself),
16 primary care physician and the Health Maintenance
17 Organization in the event of a dispute between the primary
18 care physician and the Health Maintenance Organization
19 regarding the medical necessity of a covered service proposed
20 by a primary care physician. In the event that the reviewing
21 physician determines the covered service to be medically
22 necessary, the Health Maintenance Organization shall provide
23 the covered service. Future contractual or employment action
24 by the Health Maintenance Organization regarding the primary
25 care physician shall not be based solely on the physician's
26 participation in this procedure.
27 (Source: P.A. 85-20; 85-850.)