State of Illinois
91st General Assembly
Legislation

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91_HB2185eng

 
HB2185 Engrossed                               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.)

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