Bill Text: IL HB0224 | 2011-2012 | 97th General Assembly | Engrossed

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Amends the Health Carrier External Review Act in the provision concerning standard external review. Provides that whenever a request is eligible for external review (1) the health carrier shall, within 2 (instead of 5) business days, request the Director of Insurance to assign an independent review organization (now, from the list of approved independent review organizations compiled and maintained by the Director) and (2) within 3 business days after receiving the health carrier's request, the Director shall assign, on a rotating basis, an independent review organization from the list of approved independent review organizations compiled and maintained by the Director. Includes the health carrier among those to be notified in writing by the Director of the request's eligibility and acceptance for external review. Effective immediately.

Spectrum: Partisan Bill (Democrat 7-0)

Status: (Passed) 2011-08-26 - Public Act . . . . . . . . . 97-0574 [HB0224 Detail]

Download: Illinois-2011-HB0224-Engrossed.html

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AN ACT concerning insurance.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
ARTICLE 5.
UTILIZATION REVIEW AND
BENEFIT DETERMINATION
Section 5-1. Short title. This Article may be cited as the
Utilization Review and Benefit Determination Law.
Section 5-5. Purpose and intent. This Law establishes
standards and criteria for the structure and operation of
utilization review and benefit determination processes
designed to facilitate ongoing assessment and management of
health care services.
Section 5-10. Definitions. For purposes of this Act:
"Adverse determination" has the same meaning given that
term in the Health Carrier Grievance Procedure Law.
"Ambulatory review" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Authorized representative" has the same meaning given
that term in the Health Carrier Grievance Procedure Law.
"Case management" has the same meaning given that term in

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the Health Carrier Grievance Procedure Law.
"Certification" has the same meaning given that term in the
Health Carrier Grievance Procedure Law.
"Clinical peer" has the same meaning given that term in the
Managed Care Reform and Patient Rights Law.
"Clinical review criteria" has the same meaning given that
term in the Health Carrier Grievance Procedure Law.
"Department" means the Department of Insurance.
"Director" means the Director of Insurance.
"Concurrent review" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Covered benefits" or "benefits" have the same meaning
given those terms in the Health Carrier Grievance Procedure
Law.
"Covered person" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Discharge planning" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Emergency medical condition" has the same meaning given
that term in the Health Carrier Grievance Procedure Law.
"Emergency services" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Facility" has the same meaning given that term in the
Health Carrier Grievance Procedure Law.
"Health benefit plan" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.

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"Health care professional" has the same meaning given that
term in the Health Carrier Grievance Procedure Law.
"Health care provider" or "provider" has the same meaning
given that term in the Health Carrier Grievance Procedure Law.
"Health care services" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Health carrier" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Managed care plan" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Network" has the same meaning given that term in the
Health Carrier Grievance Procedure Law.
"Participating provider" means a provider who, under a
contract with the health carrier or with its contractor or
subcontractor, has agreed to provide health care services to
covered persons with an expectation of receiving payment, other
than coinsurance, copayments, or deductibles, directly or
indirectly from the health carrier.
"Person" has the same meaning given that term in the Health
Carrier Grievance Procedure Law.
"Prospective review" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Rescission" has the same meaning given that term in the
Health Carrier Grievance Procedure Law.
"Retrospective review" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.

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"Second opinion" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Stabilization" has the same meaning given that term in the
Managed Care Reform and Patient Rights Act.
"Urgent care request" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Utilization review" has the same meaning given that term
in the Managed Care Reform and Patient Rights Act.
"Utilization review organization" means a utilization
review program as defined in the Managed Care Reform and
Patient Rights Act.
Section 5-15. Applicability and scope. This Law shall apply
to a health carrier offering a health benefit plan that
provides or performs utilization review services. The
requirements of this Law also shall apply to any designee of
the health carrier or utilization review organization that
performs utilization review functions on the carrier's behalf.
This Law also shall apply to a health carrier or its designee
utilization review organization that provides or performs
concurrent review, prospective review, or retrospective review
benefit determinations.
Section 5-20. Corporate oversight of utilization review
program. A health carrier shall be responsible for monitoring
all utilization review activities carried out by, or on behalf

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of, the health carrier and for ensuring that all requirements
of this Law and applicable regulations are met. The health
carrier also shall ensure that appropriate personnel have
operational responsibility for the conduct of the health
carrier's utilization review program.
Section 5-25. Contracting. Whenever a health carrier
contracts to have a utilization review organization or other
entity perform the utilization review functions required by
this Law or applicable regulations, the Director shall hold the
health carrier responsible for monitoring the activities of the
utilization review organization or entity with which the health
carrier contracts and for ensuring that the requirements of
this Law and applicable regulations are met.
Section 5-30. Scope and content of utilization review
program.
(a) A health carrier that requires a request for benefits
under the covered person's health benefit plan to be subjected
to utilization review shall implement a written utilization
review program that describes all review activities and
procedures, both delegated and non-delegated, for the
following:
(1) the filing of benefit requests;
(2) the notification of utilization review and benefit
determinations; and

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(3) the review of adverse determinations in accordance
with the Health Carrier Grievance Procedure Law.
(b) The program document shall describe the following:
(1) procedures to evaluate the medical necessity,
appropriateness, efficacy, or efficiency of health care
services;
(2) data sources and clinical review criteria used in
decision-making;
(3) mechanisms to ensure consistent application of
clinical review criteria and compatible decisions;
(4) data collection processes and analytical methods
used in assessing utilization of health care services;
(5) provisions for assuring confidentiality of
clinical and proprietary information;
(6) the organizational structure, including, but not
limited to, utilization review committee, quality
assurance committee, or other committee that periodically
assesses utilization review activities and reports to the
health carrier's governing body; and
(7) the staff position functionally responsible for
day-to-day program management.
(c) A health carrier shall file an annual summary report of
its utilization review program activities with the Director in
the format specified by the Director.
(d) A health carrier shall maintain records for a minimum
of 6 years of all benefit requests and claims and notices

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associated with utilization review and benefit determinations
made in accordance with Sections 5-40 and 5-45 of this Law. The
health carrier shall make the records available for examination
by covered persons and the Department upon request.
Section 5-35. Operational requirements.
(a) A utilization review program shall use documented
clinical review criteria that are based on sound clinical
evidence and are evaluated periodically to assure ongoing
efficacy. A health carrier may develop its own clinical review
criteria or it may purchase or license clinical review criteria
from qualified vendors. A health carrier shall make available
its clinical review criteria upon request to the Department.
(b) Qualified health care professionals shall administer
the utilization review program and oversee utilization review
decisions. A clinical peer shall evaluate the clinical
appropriateness of adverse determinations.
(c) A health carrier shall issue utilization review and
benefit determinations in a timely manner pursuant to the
requirements of Sections 5-40 and 5-45 of this Law.
(d) The following provisions shall apply:
(1) Whenever a health carrier fails to strictly adhere
to the requirements of Sections 5-40 or 5-45 of this Law
with respect to making utilization review and benefit
determinations of a benefit request or claim, the covered
person shall be deemed to have exhausted the provisions of

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this Law and may take action under paragraph (2) of this
subsection (d) regardless of whether the health carrier
asserts that it substantially complied with the
requirements of Sections 5-40 or 5-45 of this Law, as
applicable, or that any error it committed was de minimus.
(2) A covered person may file a request for external
review in accordance with the procedures outlined in the
Health Carrier External Review Act. In addition, a covered
person is entitled to pursue any available remedies under
State or federal law on the basis that the health carrier
failed to provide a reasonable internal claims and appeals
process that would yield a decision on the merits of the
claim.
(e) A health carrier shall have a process to ensure that
utilization reviewers apply clinical review criteria in
conducting utilization review consistently.
(f) A health carrier shall routinely assess the
effectiveness and efficiency of its utilization review
program.
(g) A health carrier's data systems shall be sufficient to
support utilization review program activities and to generate
management reports to enable the health carrier to monitor and
manage health care services effectively.
(h) If a health carrier delegates any utilization review
activities to a utilization review organization, then the
health carrier shall maintain adequate oversight, which shall

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include:
(1) a written description of the utilization review
organization's activities and responsibilities, including
reporting requirements;
(2) evidence of formal approval of the utilization
review organization program by the health carrier; and
(3) a process by which the health carrier evaluates the
performance of the utilization review organization.
(i) The health carrier shall coordinate the utilization
review program with other medical management activity
conducted by the carrier, such as quality assurance,
credentialing, provider contracting, data reporting, grievance
procedures, processes for assessing member satisfaction, and
risk management.
(j) A health carrier shall provide covered persons and
participating providers with access to its review staff by a
toll-free number or collect-call telephone line.
(k) When conducting utilization review, the health carrier
shall collect only the information necessary, including
pertinent clinical information, to make the utilization review
or benefit determination.
(l) In conducting utilization review, the health carrier
shall ensure that the review is conducted in a manner to ensure
the independence and impartiality of the individuals involved
in making the utilization review or benefit determination. In
ensuring the independence and impartially of individuals

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involved in making the utilization review or benefit
determination, the health carrier shall not make decisions
regarding hiring, compensation, termination, promotion, or
other similar matters based upon the likelihood that the
individual will support the denial of benefits.
Section 5-40. Procedures for standard utilization review
and benefit determinations.
(a) A health carrier shall maintain written procedures
pursuant to this Section for making standard utilization review
and benefit determinations on requests submitted to the health
carrier by covered persons or their authorized representatives
for benefits and for notifying covered persons and their
authorized representatives of its determinations with respect
to these requests within the specified time frames required
under this Section.
(b) Subject to subsection (d) of this Section, for
prospective review determinations, a health carrier shall make
the determination and notify the covered person or, if
applicable, the covered person's authorized representative of
the determination, whether the carrier certifies the provision
of the benefit or not, within a reasonable period of time
appropriate to the covered person's medical condition, but in
no event later than 15 days after the date the health carrier
receives the request.
(c) Whenever the determination is an adverse

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determination, the health carrier shall make the notification
of the adverse determination in accordance with subsection (q)
of this Section.
(d) The time period for making a determination and
notifying the covered person or, if applicable, the covered
person's authorized representative of the determination
pursuant to subsections (b) and (c) of this Section may be
extended one time by the health carrier for up to 15 days,
provided the health carrier:
(1) determines that an extension is necessary due to
matters beyond the health carrier's control; and
(2) notifies the covered person or, if applicable, the
covered person's authorized representative, prior to the
expiration of the initial 15-day time period, of the
circumstances requiring the extension of time and the date
by which the health carrier expects to make a
determination.
(e) If the extension under subsection (d) of this Section
is necessary due to the failure of the covered person or the
covered person's authorized representative to submit
information necessary to reach a determination on the request,
then the notice of extension shall:
(1) specifically describe the required information
necessary to complete the request; and
(2) give the covered person or, if applicable, the
covered person's authorized representative at least 45

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days from the date of receipt of the notice to provide the
specified information.
(f) Whenever the health carrier receives a prospective
review request from a covered person or the covered person's
authorized representative that fails to meet the health
carrier's filing procedures, the health carrier shall notify
the covered person or, if applicable, the covered person's
authorized representative of this failure and provide in the
notice information on the proper procedures to be followed for
filing a request.
(g) The notice required under subsection (f) of this
Section shall be provided, as soon as possible, but in no event
later than 5 days following the date of the failure. The health
carrier may provide the notice orally or, if requested by the
covered person or the covered person's authorized
representative, in writing.
(h) The provisions of subsections (f) and (g) shall apply
only in the case of a failure that:
(1) is a communication by a covered person or the
covered person's authorized representative that is
received by a person or organizational unit of the health
carrier responsible for handling benefit matters; and
(2) is a communication that refers to a specific
covered person, a specific medical condition or symptom,
and a specific health care service, treatment, or provider
for which certification is being requested.

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(i) For concurrent review determinations, if a health
carrier has certified an ongoing course of treatment to be
provided over a period of time or number of treatments, then
the following provisions shall apply:
(1) any reduction or termination by the health carrier
during the course of treatment before the end of the period
or number treatments, other than by a health benefit plan
amendment or termination of the health benefit plan, shall
constitute an adverse determination;
(2) the health carrier shall notify the covered person
of the adverse determination in accordance with subsection
(q) of this Section at a time sufficiently in advance of
the reduction or termination to allow the covered person
or, if applicable, the covered person's authorized
representative to file a grievance to request a review of
the adverse determination pursuant to the Health Carrier
Grievance Procedure Law and obtain a determination with
respect to that review of the adverse determination before
the benefit is reduced or terminated; and
(3) the health care service or treatment that is the
subject of the adverse determination shall be continued
without liability to the covered person with respect to the
internal review request made pursuant to Health Carrier
Grievance Procedure Law.
(j) For retrospective review determinations, a health
carrier shall make the determination within a reasonable period

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of time, but in no event later than 30 days after the date of
receiving the benefit request.
(k) If the determination is an adverse determination, then
the health carrier shall provide notice of the adverse
determination to the covered person or, if applicable, the
covered person's authorized representative in accordance with
subsection (q) of this Section.
(l) The time period for making a determination and
notifying the covered person or, if applicable, the covered
person's authorized representative of the determination
pursuant to subsections (j) and (k) of this Section may be
extended one time by the health carrier for up to 15 days,
provided the health carrier:
(1) determines that an extension is necessary due to
matters beyond the health carrier's control; and
(2) notifies the covered person or, if applicable, the
covered person's authorized representative, prior to the
expiration of the initial 30-day time period, of the
circumstances requiring the extension of time and the date
by which the health carrier expects to make a
determination.
(m) If the extension under subsection (l) of this Section
is necessary due to the failure of the covered person or, if
applicable, the covered person's authorized representative to
submit information necessary to reach a determination on the
request, the notice of extension shall:

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(1) specifically describe the required information
necessary to complete the request; and
(2) give the covered person or, if applicable, the
covered person's authorized representative at least 45
days after the date of receipt of the notice to provide the
specified information.
(n) For purposes of calculating the time periods within
which a determination is required to be made under this
Section, the time period within which the determination is
required to be made shall begin on the date the request is
received by the health carrier in accordance with the health
carrier's procedures established pursuant to Section 5-30 of
this Law for filing a request without regard to whether all of
the information necessary to make the determination
accompanies the filing.
(o) If the time period for making the determination under
this Section is extended due to the covered person's or, if
applicable, the covered person's authorized representative's
failure to submit the information necessary to make the
determination, the time period for making the determination
shall be tolled from the date on which the health carrier sends
the notification of the extension to the covered person or, if
applicable, the covered person's authorized representative
until the earlier of:
(1) the date on which the covered person or, if
applicable, the covered person's authorized representative

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responds to the request for additional information; or
(2) the date on which the specified information was to
have been submitted.
(p) If the covered person or the covered person's
authorized representative fails to submit the information
before the end of the period of the extension as specified in
this Section, then the health carrier may deny the
certification of the requested benefit.
(q) Notice requirements are as follows:
(1) A notification of an adverse determination under
this Section shall, in a manner calculated to be understood
by the covered person, set forth:
(A) information sufficient to identify the benefit
request or claim involved, including the date of
service, if applicable, the health care provider, the
claim amount, if applicable, the diagnosis code and its
corresponding meaning, and the treatment code and its
corresponding meaning;
(B) the specific reasons or reasons for the adverse
determination, including the denial code and its
corresponding meaning, as well as a description of the
health carrier's standard, if any, that was used in
denying the benefit request or claim;
(C) reference to the specific plan provisions on
which the determination is based;
(D) a description of any additional material or

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information necessary for the covered person to
perfect the benefit request, including an explanation
of why the material or information is necessary to
perfect the request;
(E) a description of the health carrier's
grievance procedures established pursuant to the
Health Carrier Grievance Procedure Law, including any
time limits applicable to those procedures;
(F) if the health carrier relied upon an internal
rule, guideline, protocol, or other similar criterion
to make the adverse determination, either the specific
rule, guideline, protocol, or other similar criterion
or a statement that a specific rule, guideline,
protocol, or other similar criterion was relied upon to
make the adverse determination and that a copy of the
rule, guideline, protocol, or other similar criterion
will be provided free of charge to the covered person
upon request;
(G) if the adverse determination is based on a
medical necessity or experimental or investigational
treatment or similar exclusion or limit, either an
explanation of the scientific or clinical judgment for
making the determination, applying the terms of the
health benefit plan to the covered person's medical
circumstances or a statement that an explanation will
be provided to the covered person free of charge upon

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request;
(H) a copy of the rule, guideline, protocol, or
other similar criterion relied upon in making the
adverse determination, as provided in subparagraph (F)
of this paragraph (1); or
(I) the written statement of the scientific or
clinical rationale for the adverse determination, as
provided in subparagraph (G) of this paragraph (1); and
(J) a statement explaining the availability of and
the right of the covered person, as appropriate, to
contact the Department or the Office of Consumer Health
Insurance at any time for assistance or, upon
completion of the health carrier's grievance procedure
process as provided under the Health Carrier Grievance
Procedure Law, to file a civil suit in a court of
competent jurisdiction; the statement shall include
contact information for the Department and the Office
of Consumer Health Insurance.
(2) A health carrier shall provide the notice required
under this Section in a culturally and linguistically
appropriate manner if required in accordance with federal
regulations. If a health carrier is required to provide the
notice required under this Section in a culturally and
linguistically appropriate manner in accordance with
federal regulations, then the health carrier shall:
(A) include a statement in the English version of

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the notice, prominently displayed in the non-English
language, offering the provision of the notice in the
non-English language;
(B) once a utilization review or benefit
determination request has been made by a covered
person, provide all subsequent notices to the covered
person in the non-English language; and
(C) to the extent the health carrier maintains a
consumer assistance process, such as a telephone
hotline that answers questions or provides assistance
with filing claims and appeals, provide this
assistance in the non-English language.
(3) If the adverse determination is a rescission, then
the health carrier shall, in addition to any applicable
disclosures required under this subsection (q), provide:
(A) clear identification of the alleged fraudulent
act, practice, or omission or the intentional
misrepresentation of material fact;
(B) an explanation as to why the act, practice, or
omission was fraudulent or was an intentional
misrepresentation of a material fact;
(C) notice that the covered person or the covered
person's authorized representative, prior to the
effective date of the proposed rescission, may
immediately file a grievance to request a review of the
adverse determination to rescind coverage pursuant to

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the Health Carrier Grievance Procedure Law;
(D) a description of the health carrier's
grievance procedures established pursuant to the
Health Carrier Grievance Procedure Law, including any
time limits applicable to those procedures; and
(E) the effective date of the proposed rescission
and the date back to which the coverage will be
retroactively rescinded.
(4) A health carrier must provide the notice required
under this Section in writing.
Section 5-45. Procedures for expedited utilization review
and benefit determinations.
(a) A health carrier shall establish written procedures in
accordance with this Section for receiving benefit requests
from covered persons or their authorized representatives and
for making and notifying covered persons or their authorized
representatives of expedited utilization review and benefit
determinations with respect to urgent care requests and
concurrent review urgent care requests.
(b) As part of the procedures required under subsection (a)
of this Section, a health carrier shall provide that, in the
case of a failure by a covered person or the covered person's
authorized representative to follow the health carrier's
procedures for filing an urgent care request, the covered
person or the covered person's authorized representative shall

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be notified of the failure and the proper procedures to be
followed for filing the request.
(c) The notice required under subsection (b) of this
Section:
(1) shall be provided to the covered person or the
covered person's authorized representative, as
appropriate, as soon as possible, but not later than 24
hours after receipt of the request; and
(2) may be oral, unless the covered person or the
covered person's authorized representative requests the
notice in writing.
(d) The provisions of subsections (b) and (c) of this
Section apply only in the case of a failure that:
(1) is a communication by a covered person or, if
applicable, the covered person's authorized representative
that is received by a person or organizational unit of the
health carrier responsible for handling benefit matters;
and
(2) is a communication that refers to a specific
covered person, a specific medical condition or symptom,
and a specific health care service, treatment or provider
for which approval is being requested.
(e) For an urgent care request, unless the covered person
or the covered person's authorized representative has failed to
provide sufficient information for the health carrier to
determine whether, or to what extent, the benefits requested

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are covered benefits or payable under the health carrier's
health benefit plan, the health carrier shall notify the
covered person or, if applicable, the covered person's
authorized representative of the health carrier's
determination with respect to the request, whether or not the
determination is an adverse determination, as soon as possible,
taking into account the medical condition of the covered
person, but in no event later than 24 hours after the receipt
of the request by the health carrier.
(f) If the health carrier's determination is an adverse
determination, then the health carrier shall provide notice of
the adverse determination in accordance with subsection (o) of
this Section.
(g) If the covered person or, if applicable, the covered
person's authorized representative has failed to provide
sufficient information for the health carrier to make a
determination, then the health carrier shall notify the covered
person or, if applicable, the covered person's authorized
representative either orally or, if requested by the covered
person or the covered person's authorized representative, in
writing of this failure and state what specific information is
needed as soon as possible, but in no event later than 24 hours
after receipt of the request.
(h) The health carrier shall provide the covered person or,
if applicable, the covered person's authorized representative
a reasonable period of time to submit the necessary

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information, taking into account the circumstances, but in no
event less than 48 hours after notifying the covered person or
the covered person's authorized representative of the failure
to submit sufficient information, as provided in subsection (g)
of this Section.
(i) The health carrier shall notify the covered person or,
if applicable, the covered person's authorized representative
of its determination with respect to the urgent care request as
soon as possible, but in no event more than 48 hours after the
earlier of:
(1) the health carrier's receipt of the requested
specified information; or
(2) the end of the period provided for the covered
person or, if applicable, the covered person's authorized
representative to submit the requested specified
information.
(j) If the covered person or the covered person's
authorized representative fails to submit the information
before the end of the period of the extension, as specified in
subsection (h) of this Section, then the health carrier may
deny the certification of the requested benefit.
(k) If the health carrier's determination is an adverse
determination, then the health carrier shall provide notice of
the adverse determination in accordance with subsection (o) of
this Section.
(l) For concurrent review urgent care requests involving a

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request by the covered person or the covered person's
authorized representative to extend the course of treatment
beyond the initial period of time or the number of treatments,
if the request is made at least 24 hours prior to the
expiration of the prescribed period of time or number of
treatments, then the health carrier shall make a determination
with respect to the request and notify the covered person or,
if applicable, the covered person's authorized representative
of the determination, whether it is an adverse determination or
not, as soon as possible, taking into account the covered
person's medical condition, but in no event more than 24 hours
after the health carrier's receipt of the request.
(m) If the health carrier's determination is an adverse
determination, then the health carrier shall provide notice of
the adverse determination in accordance with subsection (o) of
this Section.
(n) For purposes of calculating the time periods within
which a determination is required to be made under this
Section, the time period within which the determination is
required to be made shall begin on the date the request is
filed with the health carrier in accordance with the health
carrier's procedures established pursuant to Section 5-30 of
this Law for filing a request without regard to whether all of
the information necessary to make the determination
accompanies the filing.
(o) Notice requirements are as follows:

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(1) A notification of an adverse determination under
this Section shall, in a manner calculated to be understood
by the covered person, set forth:
(A) information sufficient to identify the benefit
request or claim involved, including the date of
service, if applicable, the health care provider, the
claim amount, if applicable, the diagnosis code and its
corresponding meaning and the treatment code and its
corresponding meaning;
(B) the specific reasons or reasons for the adverse
determination, including the denial code and its
corresponding meaning, as well as a description of the
health carrier's standard, if any, that was used in
denying the benefit request or claim;
(C) reference to the specific plan provisions on
which the determination is based;
(D) a description of any additional material or
information necessary for the covered person to
complete the request, including an explanation of why
the material or information is necessary to complete
the request;
(E) a description of the health carrier's internal
review procedures established pursuant to the Health
Carrier Grievance Procedure Law, including any time
limits applicable to those procedures;
(F) a description of the health carrier's

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expedited review procedures established pursuant to
Section 10-40 of the Health Carrier Grievance
Procedure Law;
(G) if the health carrier relied upon an internal
rule, guideline, protocol, or other similar criterion
to make the adverse determination, either the specific
rule, guideline, protocol, or other similar criterion
or a statement that a specific rule, guideline,
protocol, or other similar criterion was relied upon to
make the adverse determination and that a copy of the
rule, guideline, protocol, or other similar criterion
will be provided free of charge to the covered person
upon request;
(H) if the adverse determination is based on a
medical necessity or experimental or investigational
treatment or similar exclusion or limit, either an
explanation of the scientific or clinical judgment for
making the determination, applying the terms of the
health benefit plan to the covered person's medical
circumstances or a statement that an explanation will
be provided to the covered person free of charge upon
request;
(I) if applicable, instructions for requesting:
(i) a copy of the rule, guideline, protocol, or
other similar criterion relied upon in making the
adverse determination in accordance with

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subparagraph (G) of this paragraph (1); or
(ii) the written statement of the scientific
or clinical rationale for the adverse
determination in accordance with subparagraph (H)
of this paragraph (1); and
(J) a statement explaining the availability of and
the right of the covered person, as appropriate, to
contact the Department or the Office of Consumer Health
Insurance at any time for assistance or, upon
completion of the health carrier's grievance procedure
process as provided under the Health Carrier Grievance
Procedure Law, to file a civil suit in a court of
competent jurisdiction; the statement shall include
contact information for the Department and the Office
of Consumer Health Insurance.
(2) A health carrier shall provide the notice required
under this Section in a culturally and linguistically
appropriate manner if required in accordance with federal
regulations. If a health carrier is required to provide the
notice required under this Section in a culturally and
linguistically appropriate manner in accordance with
federal regulations, the health carrier shall do the
following:
(A) include a statement in the English version of
the notice, prominently displayed in the non-English
language, offering the provision of the notice in the

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non-English language;
(B) once a utilization review or benefit
determination request has been made by a covered
person, provide all subsequent notices to the covered
person in the non-English language; and
(C) to the extent the health carrier maintains a
consumer assistance process, such as a telephone
hotline that answers questions or provides assistance
with filing claims and appeals, the health carrier
shall provide this assistance in the non-English
language.
(3) If the adverse determination is a rescission, then
the health carrier shall provide the following, in addition
to any applicable disclosures required under this
subsection (o):
(A) clear identification of the alleged fraudulent
act, practice or omission or the intentional
misrepresentation of material fact;
(B) an explanation as to why the act, practice or
omission was fraudulent or was an intentional
misrepresentation of a material fact;
(C) the date the health carrier made the decision
to rescind the coverage; and
(D) the effective date of the proposed rescission.
(4) A health carrier may provide the notice required
under this Section orally or in writing. If notice of the

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adverse determination is provided orally, then the health
carrier shall provide written notice of the adverse
determination within 3 days following the oral
notification.
Section 5-50. Emergency services. For immediately required
post-evaluation or post-stabilization services, a health
carrier shall provide access to designated representative 24
hours a day, 7 days a week, to facilitate review.
Section 5-55. Confidentiality requirements. A health
carrier shall annually certify in writing to the Director that
the utilization review program of the health carrier or its
designee complies with all applicable State and federal law
establishing confidentiality and reporting requirements.
Section 5-60. Disclosure requirements.
(a) In the certificate of coverage or member handbook
provided to covered persons, a health carrier shall include a
clear and comprehensive description of its utilization review
procedures, including the procedures for obtaining review of
adverse determinations, and a statement of rights and
responsibilities of covered persons with respect to those
procedures.
(b) A health carrier shall include a summary of its
utilization review and benefit determination procedures in

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materials intended for prospective covered persons.
(c) A health carrier shall print on its membership cards a
toll-free telephone number to call for utilization review and
benefit decisions.
Section 5-65. Administration and enforcement.
(a) The Director of Insurance may adopt rules necessary to
implement the Department's responsibilities under this Law.
(b) The Director is authorized to make use of any of the
powers established under the Illinois Insurance Code to enforce
the laws of this State. This includes but is not limited to,
the Director's administrative authority to investigate, issue
subpoenas, conduct depositions and hearings, issue orders,
including, without limitation, orders pursuant to Article XII
1/2 and Section 401.1 of the Illinois Insurance Code, and
impose penalties.
ARTICLE 10. HEALTH CARRIER GRIEVANCE PROCEDURES
Section 10-1. Short title. This Article may be cited as the
Health Carrier Grievance Procedure Law.
Section 10-5. Purpose and intent. The purpose of this Law
is to provide standards for the establishment and maintenance
of procedures by health carriers to ensure that covered persons
have the opportunity for the appropriate resolution of

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grievances, as defined in this Law.
Section 10-10. Definitions. For purposes of this Law:
"Adverse determination" means:
(1) a determination by a health carrier or its designee
utilization review organization that, based upon the
information provided, a request for a benefit under the
health carrier's health benefit plan upon application of
any utilization review technique does not meet the health
carrier's requirements for medical necessity,
appropriateness, health care setting, level of care, or
effectiveness or is determined to be experimental or
investigational and the requested benefit is therefore
denied, reduced, or terminated or payment is not provided
or made, in whole or in part, for the benefit;
(2) the denial, reduction, termination or failure to
provide or make payment, in whole or in part, for a benefit
based on a determination by a health carrier or its
designee utilization review organization of a covered
person's eligibility to participate in the health
carrier's health benefit plan;
(3) any prospective review or retrospective review
determination that denies, reduces, or terminates or fails
to provide or make payment, in whole or in part, for a
benefit; or
(4) a rescission of coverage determination.

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"Ambulatory review" means utilization review of health
care services performed or provided in an outpatient setting.
"Authorized representative" means:
(1) a person to whom a covered person has given express
written consent to represent the covered person for
purposes of this Law;
(2) a person authorized by law to provide substituted
consent for a covered person;
(3) a family member of the covered person or the
covered person's treating health care professional when
the covered person is unable to provide consent;
(4) a health care provider when the covered person's
health benefit plan requires that a request for a benefit
under the plan be initiated by the health care provider; or
(5) in the case of an urgent care request, a health
care provider with knowledge of the covered person's
medical condition.
"Case management" means a coordinated set of activities
conducted for individual patient management of serious,
complicated, protracted, or other health conditions.
"Certification" means a determination by a health carrier
or its designee utilization review organization that a request
for a benefit under the health carrier's health benefit plan
has been reviewed and, based on the information provided,
satisfies the health carrier's requirements for medical
necessity, appropriateness, health care setting, level of

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care, and effectiveness.
"Clinical peer" has the same meaning given that term in the
Managed Care Reform and Patients Rights Act.
"Clinical review criteria" means the written screening
procedures, decision abstracts, clinical protocols, and
practice guidelines used by a health carrier to determine the
necessity and appropriateness of health care services.
"Closed plan" means a managed care plan that requires
covered persons to use participating providers under the terms
of the managed care plan.
"Director" means the Director of Insurance.
"Concurrent review" means a review conducted during a
patient's stay or course of treatment in a facility, the office
of a health care professional, or other inpatient or outpatient
health care setting.
"Covered benefits" or "benefits" means those health care
services to which a covered person is entitled under the terms
of a health benefit plan.
"Covered person" means a policyholder, subscriber,
enrollee, or other individual participating in a health benefit
plan.
"Discharge planning" means the formal process for
determining, prior to discharge from a facility, the
coordination and management of the care that a patient receives
following discharge from a facility.
"Emergency medical condition" means a medical condition

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manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson who
possesses an average knowledge of health and medicine could
reasonably expect that the absence of immediate medical
attention would result in serious impairment to bodily
functions, serious dysfunction of a bodily organ or part, or
would place the person's health or, with respect to a pregnant
woman, the health of the woman or her unborn child in serious
jeopardy.
"Emergency services" means, with respect to an emergency
medical condition:
(1) a medical screening examination that is within the
capability of the emergency department of a hospital,
including ancillary services routinely available to the
emergency department to evaluate such emergency medical
condition; and
(2) such further medical examination and treatment to
stabilize a patient, to the extent they are within the
capability of the staff and facilities available at a
hospital.
"Facility" means an institution providing health care
services or a health care setting, including, but not limited
to, hospitals and other licensed inpatient centers, ambulatory
surgical or treatment centers, skilled nursing centers,
residential treatment centers, diagnostic, laboratory and
imaging centers, and rehabilitation and other therapeutic

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health settings.
"Final adverse determination" means an adverse
determination that has been upheld by the health carrier at the
completion of the internal appeals process applicable under
Section 10-30 or Section 10-40 of this Law or an adverse
determination that with respect to which the internal appeals
process has been deemed exhausted in accordance with subsection
(b) or (c) of Section 10-25 of this Law.
"Grievance" means a written complaint or oral complaint if
the complaint involves an urgent care request submitted by or
on behalf of a covered person regarding:
(1) availability, delivery, or quality of health care
services, including a complaint regarding an adverse
determination made pursuant to utilization review;
(2) claims payment, handling, or reimbursement for
health care services; or
(3) matters pertaining to the contractual relationship
between a covered person and a health carrier.
"Health benefit plan" means a policy, contract,
certificate, or agreement offered or issued by a health carrier
to provide, deliver, arrange for, pay for, or reimburse any of
the costs of health care services. "Health benefit plan"
includes short-term and catastrophic health insurance
policies, and policies that pay on a cost-incurred basis,
except as otherwise specifically exempted in this definition.
"Health benefit plan" does not include:

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(1) coverage only for accident or disability income
insurance or any combination thereof;
(2) coverage issued as a supplement to liability
insurance;
(3) liability insurance, including general liability
insurance and automobile liability insurance;
(4) workers' compensation or similar insurance;
(5) automobile medical payment insurance;
(6) credit-only insurance;
(7) coverage for on-site medical clinics; and
(8) other similar insurance coverage, specified in
federal regulations issued pursuant to Pub. L. No. 104-191,
under which benefits for medical care are secondary or
incidental to other insurance benefits.
"Health benefit plan" does not include the following
benefits if they are provided under a separate policy,
certificate, or contract of insurance or are otherwise not an
integral part of the plan:
(1) limited scope dental or vision benefits;
(2) benefits for long-term care, nursing home care,
home health care, community-based care, or any combination
thereof; or
(3) other similar, limited benefits specified in
federal regulations issued pursuant to Pub. L. No. 104-191.
"Health benefit plan" does not include the following
benefits if the benefits are provided under a separate policy,

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certificate, or contract of insurance, there is no coordination
between the provision of the benefits and any exclusion of
benefits under any group health plan maintained by the same
plan sponsor and the benefits are paid with respect to an event
without regard to whether benefits are provided with respect to
such an event under any group health plan maintained by the
same plan sponsor:
(1) coverage only for a specified disease or illness;
or
(2) hospital indemnity or other fixed indemnity
insurance.
"Health benefit plan" does not include the following if
offered as a separate policy, certificate, or contract of
insurance:
(1) medicare supplemental health insurance as defined
under Section 1882(g)(1) of the Social Security Act;
(2) coverage supplemental to the coverage provided
under Chapter 55 of Title 10, United States Code (Civilian
Health and Medical Program of the Uniformed Services
(CHAMPUS)); or
(3) similar supplemental coverage provided to coverage
under a group health plan.
"Health care professional" means a physician or other
health care practitioner licensed, accredited, or certified to
perform specified health care services consistent with State
law.

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"Health care provider" or "provider" means a health care
professional or a facility.
"Health care services" means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
"Health carrier" means an entity subject to the insurance
laws and regulations of this State, or subject to the
jurisdiction of the Director, that contracts or offers to
contract to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services, including a
sickness and accident insurance company, a health maintenance
organization, a nonprofit hospital and health service
corporation, or any other entity providing a plan of health
insurance, health benefits or health care services.
"Health indemnity plan" means a health benefit plan that is
not a managed care plan.
"Managed care plan" means a health benefit plan that
requires a covered person to use or creates incentives,
including financial incentives, for a covered person to use
health care providers managed, owned, under contract with, or
employed by the health carrier. "Managed care plan" includes:
(1) a closed plan, as defined in this Law; and
(2) an open plan, as defined in this Law.
"Network" means the group of participating providers
providing services to a managed care plan.
"Open plan" means a managed care plan other than a closed

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plan that provides incentives, including financial incentives,
for covered persons to use participating providers under the
terms of the managed care plan.
"Person" means an individual, a corporation, a
partnership, an association, a joint venture, a joint stock
company, a trust, an unincorporated organization, any similar
entity, or any combination of the foregoing.
"Prospective review" means a review conducted prior to an
admission or the provision of a health care service or a course
of treatment in accordance with a health carrier's requirement
that the health care service or course of treatment, in whole
or in part, be approved prior to its provision.
"Rescission" means a cancellation or discontinuance of
coverage under a health benefit plan that has a retroactive
effect. "Rescission" does not include a cancellation or
discontinuance of coverage under a health benefit plan if:
(1) the cancellation or discontinuance of coverage has
only a prospective effect; or
(2) the cancellation or discontinuance of coverage is
effective retroactively to the extent it is attributable to
a failure to timely pay required premiums or contributions
towards the cost of coverage.
"Retrospective review" means any review of a request for a
benefit that is not a concurrent or prospective review request.
"Retrospective review" does not include the review of a claim
that is limited to veracity of documentation or accuracy of

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coding.
"Second opinion" means an opportunity or requirement to
obtain a clinical evaluation by a provider other than the one
originally making a recommendation for a proposed health care
service to assess the medical necessity and appropriateness of
the initially proposed health care service.
"Stabilization" has the same meaning given that term in
Managed Care Reform and Patient Rights Act.
"Urgent care request" means a request for a health care
service or course of treatment with respect to which the time
periods for making non-urgent care request determination:
(1) could seriously jeopardize the life or health of
the covered person or the ability of the covered person to
regain maximum function; or
(2) in the opinion of a physician with knowledge of the
covered person's medical condition, would subject the
covered person to severe pain that cannot be adequately
managed without the health care service or treatment that
is the subject of the request.
Except as provided in item (2) of this definition of
"urgent care request", in determining whether a request is to
be treated as an urgent care request, an individual acting on
behalf of the health carrier shall apply the judgment of a
prudent layperson who possesses an average knowledge of health
and medicine.
Any request that a physician with knowledge of the covered

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person's medical condition determines is an urgent care request
shall be treated as an urgent care request.
"Utilization review" has the same meaning given that term
in Managed Care Reform and Patient Rights Act.
"Utilization review organization" means a utilization
review program as defined in the Managed Care Reform and
Patient Rights Act.
Section 10-15. Applicability and scope. Except as
otherwise specified, this Law shall apply to all health
carriers offering a health benefit plan.
Section 10-20. Grievance reporting and record-keeping
requirements.
(a) A health carrier shall maintain written records to
document all grievances received, including the notices and
claims associated with the grievances, during a calendar year.
(b) Notwithstanding the provisions under subsections (g)
and (h) of this Section, a health carrier shall maintain the
records required under subsection (a) of this Section for at
least 6 years related to the notices provided under subsection
(g) of Section 10-30 and subsection (h) of Section 10-40 of
this Law.
(c) The health carrier shall make the records available for
examination by covered persons and the Director upon request,
and shall annually file a copy of the register with the

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Department. The Department shall make a summary of all data
collected available upon request and shall publish the summary
on the World Wide Web. No Department publication or release of
information shall identify any enrollee, health care provider,
or individual complainant.
(d) A request for a review of a grievance involving an
adverse determination shall be processed in compliance with
Section 10-30 of this Law and shall be included in the
register.
(e) For each grievance the register shall contain, at a
minimum, the following information:
(1) an indication regarding whether the grievance was
filed by:
(A) a consumer or enrollee;
(B) a provider; or
(C) any other individual;
(2) classification of the grievance under one of the
following categories:
(A) denial of care or treatment;
(B) denial of a diagnostic procedure;
(C) denial of a referral request;
(D) sufficient choice and accessibility of health
care providers;
(E) underwriting;
(F) marketing and sales;
(G) claims and utilization review;

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(H) member services;
(I) provider relations; and
(J) miscellaneous;
(3) a general description of the reason for the
grievance;
(4) the date received;
(5) the date of each review or, if applicable, review
meeting;
(6) resolution at each level of the grievance, if
applicable;
(7) the date of resolution at each level, if
applicable; and
(8) the name of the covered person for whom the
grievance was filed.
(f) The register shall be maintained in a manner that is
reasonably clear and accessible to the Director.
(g) Subject to the provisions of subsection (a) of this
Section, a health carrier shall retain the register compiled
for a calendar year for the longer of 3 years or until the
Director has adopted a final report of an examination that
contains a review of the register for that calendar year.
(h) A health carrier shall submit to the Director, at least
annually, a report in the format specified by the Director. The
report shall include for each type of health benefit plan
offered by the health carrier:
(1) the certificate of compliance required by Section

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10-25 of this Law;
(2) the number of covered lives;
(3) the total number of grievances;
(4) the number of grievances resolved at each level, if
applicable, and their resolution;
(5) the number of grievances appealed to the Director
of which the health carrier has been informed;
(6) the number of grievances referred to alternative
dispute resolution procedures or resulting in litigation;
and
(7) a synopsis of actions being taken to correct
problems identified.
Section 10-25. Grievance review procedures.
(a) Except as specified in Section 10-40 of this Law, a
health carrier shall use written procedures for receiving and
resolving grievances from covered persons, as provided in
Sections 10-30 and 10-35 of this Law.
(b) The following provisions shall apply:
(1) Whenever a health carrier fails to strictly adhere
to the requirements of Section 10-30 or Section 10-40 of
this Law with respect to receiving and resolving grievances
involving an adverse determination, the covered person
shall be deemed to have exhausted the provisions of this
Law and may take action under paragraph (2) of this
subsection (b) regardless of whether the health carrier

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asserts that it substantially complied with the
requirements of Section 10-30 or Section 10-40, as
applicable, or that any error it committed was de minimus.
(2) A covered person may file a request for external
review in accordance with the procedures outlined in the
Health Carrier External Review Act. In addition, a covered
person is entitled to pursue any available remedies under
State or federal law on the basis that the health carrier
failed to provide a reasonable internal claims and appeals
process that would yield a decision on the merits of the
claim.
(c) A health carrier shall file a copy of the procedures
required under subsections (a) and (b) of this Section,
including all forms used to process requests made pursuant to
Sections 10-30 and 10-35 of this Law, with the Director. Any
subsequent modifications to the documents also shall be filed.
(d) The Director may disapprove a filing received in
accordance with subsection (c) of this Section that fails to
comply with this Law or applicable regulations.
(e) A health carrier shall file annually with the Director,
as part of its annual report required by Section 10-20 of this
Law, a certificate of compliance stating that the health
carrier has established and maintains, for each of its health
benefit plans, grievance procedures that fully comply with the
provisions of this Law.
(f) A description of the grievance procedures required

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under this Section shall be set forth in or attached to the
policy, certificate, membership booklet, outline of coverage
or other evidence of coverage provided to covered persons.
(g) The grievance procedure documents shall include a
statement of a covered person's right to contact the Department
or the Office of Consumer Health Insurance for assistance at
any time. The statement shall include the telephone number and
address of the Department and the Office of Consumer Health
Insurance.
Section 10-30. Reviews of grievances involving an adverse
determination.
(a) Within 180 days after the date of receipt of a notice
of an adverse determination sent pursuant to the Managed Care
Reform and Patient Rights Act, a covered person or the covered
person's authorized representative may file a grievance with
the health carrier requesting a review of the adverse
determination.
(b) The health carrier shall provide the covered person
with the name, address, and telephone number of a person or
organizational unit designated to coordinate the review on
behalf of the health carrier.
(c) In providing for a review under this Section, the
health carrier shall ensure that the review is conducted in a
manner under this Section to ensure the independence and
impartiality of the individuals involved in making the review

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decision.
(d) In ensuring the independence and impartially of
individuals involved in making the review decision, the health
carrier shall not make decisions related to such individuals
regarding hiring, compensation, termination, promotion, or
other similar matters based upon the likelihood that the
individual will support the denial of benefits.
(e) In the case of an adverse determination involving
utilization review, the health carrier shall designate an
appropriate clinical peer or peers of the same or similar
specialty as would typically manage the case being reviewed to
review the adverse determination. The clinical peer shall not
have been involved in the initial adverse determination.
(f) In designating an appropriate clinical peer or peers
pursuant to subsection (e) of this Section, the health carrier
shall ensure that, if more than one clinical peer is involved
in the review, a majority of the individuals reviewing the
adverse determination are health care professionals who have
appropriate expertise.
(g) In conducting a review under this Section, the reviewer
or reviewers shall take into consideration all comments,
documents, records, and other information regarding the
request for services submitted by the covered person or the
covered person's authorized representative, without regard to
whether the information was submitted or considered in making
the initial adverse determination.

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(h) A covered person does not have the right to attend or
to have a representative in attendance at the review, but the
covered person or, if applicable, the covered person's
authorized representative is entitled to:
(1) submit written comments, documents, records, and
other material relating to the request for benefits for the
reviewer or reviewers to consider when conducting the
review; and
(2) receive from the health carrier, upon request and
free of charge, reasonable access to and copies of all
documents, records, and other information relevant to the
covered person's request for benefits.
(i) For purposes of paragraph (2) of subsection (h) of this
Section, a document, record, or other information shall be
considered "relevant" to a covered person's request for
benefits if the document, record, or other information:
(1) was relied upon in making the benefit
determination;
(2) was submitted, considered, or generated in the
course of making the adverse determination, without regard
to whether the document, record, or other information was
relied upon in making the benefit determination;
(3) demonstrates that, in making the benefit
determination, the health carrier or its designated
representatives consistently applied required
administrative procedures and safeguards with respect to

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the covered person as other similarly situated covered
persons; or
(4) constitutes a statement of policy or guidance with
respect to the health benefit plan concerning the denied
health care service or treatment for the covered person's
diagnosis, without regard to whether the advice or
statement was relied upon in making the benefit
determination.
(j) The health carrier shall make the provisions of
subsections (h) and (i) of this Section known to the covered
person or, if applicable, the covered person's authorized
representative within 3 business days after the date of receipt
of the grievance.
(k) For purposes of calculating the time periods within
which a determination is required to be made and notice
provided under subsections (l), (m), and (n) of this Section,
the time period shall begin on the date the grievance
requesting the review is filed with the health carrier in
accordance with the health carrier's procedures established
pursuant to Section 10-25 of this Law for filing a request
without regard to whether all of the information necessary to
make the determination accompanies the filing.
(l) A health carrier shall notify and issue a decision in
writing or electronically to the covered person or, if
applicable, the covered person's authorized representative
within the time frames provided in subsection (m) or (n) of

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this Section.
(m) With respect to a grievance requesting a review of an
adverse determination involving a prospective review request,
the health carrier shall notify and issue a decision within a
reasonable period of time that is appropriate given the covered
person's medical condition, but no later than 30 days after the
date of the health carrier's receipt of the grievance
requesting the review made pursuant to subsection (a) of this
Section.
(n) With respect to a grievance requesting a review of an
adverse determination involving a retrospective review
request, the health carrier shall notify and issue a decision
within a reasonable period of time, but no later than 60 days
after the date of the health carrier's receipt of the grievance
requesting the review made pursuant to subsection (a) of this
Section.
(o) Prior to issuing a decision in accordance with the
timeframes provided in subsection (m) or (n) of this Section,
the health carrier shall provide free of charge to the covered
person, or the covered person's authorized representative, any
new or additional evidence relied upon or generated by the
health carrier or at the direction of the health carrier, in
connection with the grievance sufficiently in advance of the
date the decision is required to be provided to permit the
covered person or the covered person's authorized
representative, a reasonable opportunity to respond prior to

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that date.
(p) Before the health carrier issues or provides notice of
a final adverse determination in accordance with the timeframes
provided in subsection (m) or (n) of this Section that is based
on new or additional rationale, the health carrier shall
provide the new or additional rationale to the covered person
or the covered person's authorized representative free of
charge as soon as possible and sufficiently in advance of the
date the notice of final adverse determination is to be
provided to permit the covered person or the covered person's
authorized representative a reasonable opportunity to respond
prior to that date.
The decision issued pursuant to subsection (m) or (n) of
this Section shall set forth the following in a manner
calculated to be understood by the covered person or, if
applicable, the covered person's authorized representative:
(1) the titles and qualifying credentials of the person
or persons participating in the review process (the
reviewers);
(2) information sufficient to identify the claim
involved with respect to the grievance, including the date
of service, the health care provider, if applicable, the
claim amount, the diagnosis code and its corresponding
meaning, and the treatment code and its corresponding
meaning;
(3) a statement of the reviewers' understanding of the

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covered person's grievance;
(4) the reviewers' decision in clear terms and the
contract basis or medical rationale in sufficient detail
for the covered person to respond further to the health
carrier's position;
(5) a reference to the evidence or documentation used
as the basis for the decision;
(6) for a decision issued pursuant to this Section that
upholds the grievance:
(A) the specific reason or reasons for the final
adverse determination, including the denial code and
its corresponding meaning, as well as a description of
the health carrier's standard, if any, that was used in
reaching the denial;
(B) the reference to the specific plan provisions
on which the determination is based;
(C) a statement that the covered person is entitled
to receive, upon request and free of charge, reasonable
access to and copies of all documents, records, and
other information relevant, as the term "relevant" is
defined in subsection (i) of this Section, to the
covered person's benefit request;
(D) if the health carrier relied upon an internal
rule, guideline, protocol, or other similar criterion
to make the final adverse determination, either the
specific rule, guideline, protocol, or other similar

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criterion or a statement that a specific rule,
guideline, protocol, or other similar criterion was
relied upon to make the final adverse determination and
that a copy of the rule, guideline, protocol, or other
similar criterion will be provided free of charge to
the covered person upon request;
(E) if the final adverse determination is based on
a medical necessity or experimental or investigational
treatment or similar exclusion or limit, either an
explanation of the scientific or clinical judgment for
making the determination, applying the terms of the
health benefit plan to the covered person's medical
circumstances or a statement that an explanation will
be provided to the covered person free of charge upon
request; and
(F) if applicable, instructions for requesting:
(i) a copy of the rule, guideline, protocol or
other similar criterion relied upon in making the
final adverse determination, as provided in
subparagraph (D) of paragraph (6) of subsection
(p) of this Section; and
(ii) the written statement of the scientific
or clinical rationale for the determination, as
provided in subparagraph (E) of paragraph (6) of
subsection (p) of this Section;
(G) If applicable, a statement indicating:

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(i) a description of the procedures for
obtaining an independent external review of the
final adverse determination pursuant to the Health
Carrier External Review Act; and
(ii) the covered person's right to bring a
civil action in a court of competent jurisdiction;
and
(iii) notice of the covered person's right to
contact the Department or the Office of Consumer
Health Insurance for assistance with respect to
any claim, grievance, or appeal at any time,
including the telephone number and address of the
Department and the Office of Consumer Health
Insurance.
(q) A health carrier shall provide the notice required
under subsection (p) of this Section in a culturally and
linguistically appropriate manner if required in accordance
with federal regulations. If a health carrier is required to
provide the notice in a culturally and linguistically
appropriate manner in accordance with federal regulations,
then the health carrier shall:
(1) include a statement in the English version of the
notice, prominently displayed in the non-English language,
offering the provision of the notice in the non-English
language;
(2) once a utilization review or benefit determination

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request has been made by a covered person, provide all
subsequent notices to the covered person in the non-English
language; and
(3) to the extent the health carrier maintains a
consumer assistance process, such as a telephone hotline
that answers questions or provides assistance with filing
claims and appeals, the health carrier shall provide this
assistance in the non-English language.
Section 10-35. Standard reviews of grievances not
involving an adverse determination.
(a) A health carrier shall establish written procedures for
a standard review of a grievance that does not involve an
adverse determination.
(b) The procedures shall permit a covered person or the
covered person's authorized representative to file a grievance
that does not involve an adverse determination with the health
carrier under this Section.
(c) A covered person does not have the right to attend or
to have a representative in attendance at the standard review,
but the covered person or the covered person's authorized
representative is entitled to submit written material for the
person or persons designated by the carrier pursuant to
subsection (e) of this Section to consider when conducting the
review.
(d) The health carrier shall make the provisions of

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subsection (c) of this Section known to the covered person or,
if applicable, the covered person's authorized representative
within 3 business days after the date of receiving the
grievance.
(e) Upon receipt of the grievance, a health carrier shall
designate a person or persons to conduct the standard review of
the grievance. The health carrier shall not designate the same
person or persons to conduct the standard review of the
grievance that denied the claim or handled the matter that is
the subject of the grievance. The health carrier shall provide
the covered person or, if applicable, the covered person's
authorized representative with the name, address, and
telephone number of a person designated to coordinate the
standard review on behalf of the health carrier.
(f) The health carrier shall notify in writing the covered
person or, if applicable, the covered person's authorized
representative of the decision within 20 business days after
the date of receipt of the request for a standard review of a
grievance filed pursuant to this Section.
(g) Subject to subsection (h) of this Section, if, due to
circumstances beyond the carrier's control, the health carrier
cannot make a decision and notify the covered person or, if
applicable, the covered person's authorized representative
pursuant to subsection (f) of this Section within 20 business
days, the health carrier may take up to an additional 10
business days to issue a written decision.

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(h) A health carrier may extend the time for making and
notifying the covered person or, if applicable, the covered
person's authorized representative in accordance with
subsection (g) of this Section, if, on or before the 20th
business day after the date of receiving the request for a
standard review of a grievance, the health carrier provides
written notice to the covered person or, if applicable, the
covered person's authorized representative of the extension
and the reasons for the delay.
(i) The written decision issued pursuant to this Section
shall contain all of the following:
(1) The titles and qualifying credentials of the person
or persons participating in the standard review process
(the reviewers).
(2) A statement of the reviewers' understanding of the
covered person's grievance.
(3) The reviewers' decision in clear terms and the
contract basis in sufficient detail for the covered person
to respond further to the health carrier's position.
(4) Reference to the evidence or documentation used as
the basis for the decision.
(5) Notice of the covered person's right, at any time,
to contact the Department or the Office of Consumer Health
Insurance, including the telephone number and address of
the Department and the Office of Consumer Health Insurance.

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Section 10-40. Expedited reviews of grievances involving
an adverse determination.
(a) A health carrier shall establish written procedures for
the expedited review of urgent care requests of grievances
involving an adverse determination.
(b) In addition to subsection (a) of this Section, a health
carrier shall provide an expedited review of a grievance
involving an adverse determination with respect to concurrent
review urgent care requests involving an admission,
availability of care, continued stay or health care service for
a covered person who has received emergency services, but has
not been discharged from a facility.
(c) The procedures shall allow a covered person or the
covered person's authorized representative to request an
expedited review under this Section orally or in writing.
(d) A health carrier shall appoint an appropriate clinical
peer or peers in the same or similar specialty as would
typically manage the case being reviewed to review the adverse
determination. The clinical peer or peers shall not have been
involved in making the initial adverse determination.
(e) In an expedited review, all necessary information,
including the health carrier's decision, shall be transmitted
between the health carrier and the covered person or, if
applicable, the covered person's authorized representative by
telephone, facsimile, or the most expeditious method
available.

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(f) An expedited review decision shall be made and the
covered person or, if applicable, the covered person's
authorized representative shall be notified of the decision in
accordance with this Section as expeditiously as the covered
person's medical condition requires, but in no event more than
48 hours after the receipt of the request for the expedited
review. If the expedited review is of a grievance involving an
adverse determination with respect to a concurrent review
urgent care request, the service shall be continued without
liability to the covered person until the covered person has
been notified of the determination.
(g) For purposes of calculating the time periods within
which a decision is required to be made under subsection (f) of
this Section, the time period within which the decision is
required to be made shall begin on the date the request is
filed with the health carrier in accordance with the health
carrier's procedures established pursuant to Section 10-25 of
this Law for filing a request without regard to whether all of
the information necessary to make the determination
accompanies the filing.
(h) A notification of a decision under this Section shall,
in a manner calculated to be understood by the covered person
or, if applicable, the covered person's authorized
representative, set forth:
(1) the titles and qualifying credentials of the person
or persons participating in the expedited review process

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(the reviewers);
(2) information sufficient to identify the claim
involved with respect to the grievance, including the date
of service, the health care provider, if applicable, the
claim amount, the diagnosis code and its corresponding
meaning, and the treatment code and its corresponding
meaning;
(3) a statement of the reviewers' understanding of the
covered person's grievance;
(4) the reviewers' decision in clear terms and the
contract basis or medical rationale in sufficient detail
for the covered person to respond further to the health
carrier's position;
(5) a reference to the evidence or documentation used
as the basis for the decision; and
(6) if the decision involves a final adverse
determination, then the notice shall provide:
(A) the specific reasons or reasons for the final
adverse determination, including the denial code and
its corresponding meaning, as well as a description of
the health carrier's standard, if any, that was used in
reaching the denial;
(B) reference to the specific plan provisions on
which the determination is based;
(C) a description of any additional material or
information necessary for the covered person to

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complete the request, including an explanation of why
the material or information is necessary to complete
the request;
(D) if the health carrier relied upon an internal
rule, guideline, protocol, or other similar criterion
to make the adverse determination, then either the
specific rule, guideline, protocol, or other similar
criterion or a statement that a specific rule,
guideline, protocol, or other similar criterion was
relied upon to make the adverse determination and that
a copy of the rule, guideline, protocol, or other
similar criterion will be provided free of charge to
the covered person upon request;
(E) if the final adverse determination is based on
a medical necessity or experimental or investigational
treatment or similar exclusion or limit, then either an
explanation of the scientific or clinical judgment for
making the determination, applying the terms of the
health benefit plan to the covered person's medical
circumstances or a statement that an explanation will
be provided to the covered person free of charge upon
request;
(F) If applicable, instructions for requesting:
(i) a copy of the rule, guideline, protocol or
other similar criterion relied upon in making the
adverse determination in accordance with

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subparagraph (4) of paragraph (F) of subsection
(h) of this Section; or
(ii) the written statement of the scientific
or clinical rationale for the adverse
determination in accordance with subparagraph (5)
of paragraph (F) of subsection (h) of this Section;
(G) a statement describing the procedures for
obtaining an independent external review of the
adverse determination pursuant to the Health Carrier
External Review Act;
(H) a statement indicating the covered person's
right to bring a civil action in a court of competent
jurisdiction; and
(I) a notice of the covered person's right to
contact the Department or the Office of Consumer Health
Insurance for assistance with respect to the claim,
grievance or appeal at any time, including the
telephone number and address of the Department and the
Office of Consumer Health Insurance.
(i) A health carrier shall provide the notice required
under this Section in a culturally and linguistically
appropriate manner if required in accordance with federal
regulations.
(j) If a health carrier is required to provide the notice
required under this Section in a culturally and linguistically
appropriate manner in accordance with federal regulations,

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then the health carrier shall:
(1) include a statement in the English version of the
notice, prominently displayed in the non-English language,
offering the provision of the notice in the non- English
language;
(2) once a utilization review or benefit determination
request has been made by a covered person, provide all
subsequent notices to the covered person in the non-
English language; and
(3) to the extent the health carrier maintains a
consumer assistance process, such as a telephone hotline
that answers questions or provides assistance with filing
claims and appeals, the health carrier shall provide this
assistance in the non-English language.
(k) A health carrier may provide the notice required under
this Section orally, in writing, or electronically.
(l) If notice of the adverse determination is provided
orally, then the health carrier shall provide written or
electronic notice of the adverse determination within 3 days
following the oral notification.
Section 10-45. Administration and enforcement.
(a) The Director of Insurance may adopt rules necessary to
implement the Department's responsibilities under this Law.
(b) The Director is authorized to make use of any of the
powers established under the Illinois Insurance Code to enforce

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the laws of this State. This includes but is not limited to,
the Director's administrative authority to investigate, issue
subpoenas, conduct depositions and hearings, issue orders,
including, without limitation, orders pursuant to Article XII
1/2 and Section 401.1 of the Illinois Insurance Code, and
impose penalties.
ARTICLE 90. AMENDATORY PROVISIONS
Section 90-5. The Managed Care Reform and Patient Rights
Act is amended by changing Sections 10, 45, and 85 as follows:
(215 ILCS 134/10)
Sec. 10. Definitions:
"Adverse determination" has the same meaning given that
term in the Health Carrier Grievance Procedure Law means a
determination by a health care plan under Section 45 or by a
utilization review program under Section 85 that a health care
service is not medically necessary.
"Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
"Covered person" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Department" means the Department of Insurance.

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"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including, but not limited to, severe pain) such that a
prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed to
practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
"Enrollee" means any person and his or her dependents

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enrolled in or covered by a health care plan.
"Health benefit plan" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Health care plan" means a plan that establishes, operates,
or maintains a network of health care providers that has
entered into an agreement with the plan to provide health care
services to enrollees to whom the plan has the ultimate
obligation to arrange for the provision of or payment for
services through organizational arrangements for ongoing
quality assurance, utilization review programs, or dispute
resolution. Nothing in this definition shall be construed to
mean that an independent practice association or a physician
hospital organization that subcontracts with a health care plan
is, for purposes of that subcontract, a health care plan.
For purposes of this definition, "health care plan" shall
not include the following:
(1) indemnity health insurance policies including
those using a contracted provider network;
(2) health care plans that offer only dental or only
vision coverage;
(3) preferred provider administrators, as defined in
Section 370g(g) of the Illinois Insurance Code;
(4) employee or employer self-insured health benefit
plans under the federal Employee Retirement Income
Security Act of 1974;
(5) health care provided pursuant to the Workers'

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Compensation Act or the Workers' Occupational Diseases
Act; and
(6) not-for-profit voluntary health services plans
with health maintenance organization authority in
existence as of January 1, 1999 that are affiliated with a
union and that only extend coverage to union members and
their dependents.
"Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.
"Health care provider" means any physician, hospital
facility, or other person that is licensed or otherwise
authorized to deliver health care services. Nothing in this Act
shall be construed to define Independent Practice Associations
or Physician-Hospital Organizations as health care providers.
"Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all other
services for the purpose of preventing, alleviating, curing, or
healing human illness or injury including home health and
pharmaceutical services and products.
"Health carrier" has the same meaning given that term in
the Health Carrier Grievance Procedure Law.
"Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health

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care plan.
"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
"Physician" means a person licensed under the Medical
Practice Act of 1987.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
"Prospective review" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Rescission" has the same meaning given that term in the
Health Carrier Grievance Procedure Law.
"Retrospective review" has the same meaning given that term
in the Health Carrier Grievance Procedure Law.
"Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
"Utilization review" means a set of formal techniques
designed to monitor the use of, or evaluate the evaluation of
the medical necessity, appropriateness, efficacy, or and

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efficiency of, the use of health care services, procedures,
settings or and facilities.
"Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 91-617, eff. 1-1-00.)
(215 ILCS 134/45)
Sec. 45. Appeals of external Health care services appeals,
complaints, and external independent reviews.
(a) (Blank). A health care plan shall establish and
maintain an appeals procedure as outlined in this Act.
Compliance with this Act's appeals procedures shall satisfy a
health care plan's obligation to provide appeal procedures
under any other State law or rules. All appeals of a health
care plan's administrative determinations and complaints
regarding its administrative decisions shall be handled as
required under Section 50.
(b) (Blank). When an appeal concerns a decision or action
by a health care plan, its employees, or its subcontractors
that relates to (i) health care services, including, but not
limited to, procedures or treatments, for an enrollee with an
ongoing course of treatment ordered by a health care provider,
the denial of which could significantly increase the risk to an
enrollee's health, or (ii) a treatment referral, service,
procedure, or other health care service, the denial of which
could significantly increase the risk to an enrollee's health,

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the health care plan must allow for the filing of an appeal
either orally or in writing. Upon submission of the appeal, a
health care plan must notify the party filing the appeal, as
soon as possible, but in no event more than 24 hours after the
submission of the appeal, of all information that the plan
requires to evaluate the appeal. The health care plan shall
render a decision on the appeal within 24 hours after receipt
of the required information. The health care plan shall notify
the party filing the appeal and the enrollee, enrollee's
primary care physician, and any health care provider who
recommended the health care service involved in the appeal of
its decision orally followed-up by a written notice of the
determination.
(c) (Blank). For all appeals related to health care
services including, but not limited to, procedures or
treatments for an enrollee and not covered by subsection (b)
above, the health care plan shall establish a procedure for the
filing of such appeals. Upon submission of an appeal under this
subsection, a health care plan must notify the party filing an
appeal, within 3 business days, of all information that the
plan requires to evaluate the appeal. The health care plan
shall render a decision on the appeal within 15 business days
after receipt of the required information. The health care plan
shall notify the party filing the appeal, the enrollee, the
enrollee's primary care physician, and any health care provider
who recommended the health care service involved in the appeal

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orally of its decision followed-up by a written notice of the
determination.
(d) (Blank). An appeal under subsection (b) or (c) may be
filed by the enrollee, the enrollee's designee or guardian, the
enrollee's primary care physician, or the enrollee's health
care provider. A health care plan shall designate a clinical
peer to review appeals, because these appeals pertain to
medical or clinical matters and such an appeal must be reviewed
by an appropriate health care professional. No one reviewing an
appeal may have had any involvement in the initial
determination that is the subject of the appeal. The written
notice of determination required under subsections (b) and (c)
shall include (i) clear and detailed reasons for the
determination, (ii) the medical or clinical criteria for the
determination, which shall be based upon sound clinical
evidence and reviewed on a periodic basis, and (iii) in the
case of an adverse determination, the procedures for requesting
an external independent review as provided by the Illinois
Health Carrier External Review Act.
(e) (Blank). If an appeal filed under subsection (b) or (c)
is denied for a reason including, but not limited to, the
service, procedure, or treatment is not viewed as medically
necessary, denial of specific tests or procedures, denial of
referral to specialist physicians or denial of hospitalization
requests or length of stay requests, any involved party may
request an external independent review as provided by the

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Illinois Health Carrier External Review Act.
(f) Until July 1, 2013, if an external independent review
decision made pursuant to the Illinois Health Carrier External
Review Act upholds a determination adverse to the covered
person, the covered person has the right to appeal the final
decision to the Department; if the external review decision is
found by the Director to have been arbitrary and capricious,
then the Director, with consultation from a licensed medical
professional, may overturn the external review decision and
require the health carrier to pay for the health care service
or treatment; such decision, if any, shall be made solely on
the legal or medical merits of the claim. If an external review
decision is overturned by the Director pursuant to this Section
and the health carrier so requests, then the Director shall
assign a new independent review organization to reconsider the
overturned decision. The new independent review organization
shall follow subsection (d) of Section 40 of the Health Carrier
External Review Act in rendering a decision.
(g) Future contractual or employment action by the health
care plan regarding the patient's physician or other health
care provider shall not be based solely on the physician's or
other health care provider's participation in health care
services appeals, complaints, or external independent reviews
under the Illinois Health Carrier External Review Act.
(h) Nothing in this Section shall be construed to require a
health care plan to pay for a health care service not covered

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under the terms of the enrollee's certificate of coverage or
policy, unless the terms are inconsistent with applicable law.
(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 134/85)
Sec. 85. Utilization review program registration.
(a) No person may conduct a utilization review program in
this State unless once every 2 years the person registers the
utilization review program with the Department and certifies
compliance with the Health Utilization Management Standards of
the American Accreditation Healthcare Commission (URAC)
sufficient to achieve American Accreditation Healthcare
Commission (URAC) accreditation or submits evidence of
accreditation by the American Accreditation Healthcare
Commission (URAC) for its Health Utilization Management
Standards. Nothing in this Act shall be construed to require a
health carrier care plan or its subcontractors to become
American Accreditation Healthcare Commission (URAC)
accredited.
(b) In addition, the Director of the Department, in
consultation with the Director of the Department of Public
Health, may certify alternative utilization review standards
of national accreditation organizations or entities in order
for plans to comply with this Section. Any alternative
utilization review standards shall meet or exceed those
standards required under subsection (a).

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(c) The provisions of this Section do not apply to:
(1) persons providing utilization review program
services only to the federal government;
(2) self-insured health plans under the federal
Employee Retirement Income Security Act of 1974, however,
this Section does apply to persons conducting a utilization
review program on behalf of these health plans;
(3) hospitals and medical groups performing
utilization review activities for internal purposes unless
the utilization review program is conducted for another
person.
Nothing in this Act prohibits a health care plan or other
entity from contractually requiring an entity designated in
item (3) of this subsection to adhere to the utilization review
program requirements of this Act.
(d) This registration shall include submission of all of
the following information regarding utilization review program
activities:
(1) The name, address, and telephone number of the
utilization review programs.
(2) The organization and governing structure of the
utilization review programs.
(3) The number of lives for which utilization review is
conducted by each utilization review program.
(4) Hours of operation of each utilization review
program.

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(5) Description of the grievance process for each
utilization review program.
(6) Number of covered lives for which utilization
review was conducted for the previous calendar year for
each utilization review program.
(7) Written policies and procedures for protecting
confidential information according to applicable State and
federal laws for each utilization review program.
(e) (1) A utilization review program shall have written
procedures for assuring that patient-specific information
obtained during the process of utilization review will be:
(A) kept confidential in accordance with applicable
State and federal laws; and
(B) shared only with the enrollee, the enrollee's
designee, the enrollee's health care provider, and those
who are authorized by law to receive the information.
Summary data shall not be considered confidential if it
does not provide information to allow identification of
individual patients or health care providers.
(2) Only a health care professional may make
determinations regarding the medical necessity of health
care services during the course of utilization review.
(3) When making retrospective reviews, utilization
review programs shall base reviews solely on the medical
information available to the attending physician or
ordering provider at the time the health care services were

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provided.
(4) When making prospective, concurrent, and
retrospective determinations, utilization review programs
shall collect only information that is necessary to make
the determination and shall not routinely require health
care providers to numerically code diagnoses or procedures
to be considered for certification, unless required under
State or federal Medicare or Medicaid rules or regulations,
but may request such code if available, or routinely
request copies of medical records of all enrollees
reviewed. During prospective or concurrent review, copies
of medical records shall only be required when necessary to
verify that the health care services subject to review are
medically necessary. In these cases, only the necessary or
relevant sections of the medical record shall be required.
(f) If the Department finds that a utilization review
program is not in compliance with this Section, the Department
shall issue a corrective action plan and allow a reasonable
amount of time for compliance with the plan. If the utilization
review program does not come into compliance, the Department
may issue a cease and desist order. Before issuing a cease and
desist order under this Section, the Department shall provide
the utilization review program with a written notice of the
reasons for the order and allow a reasonable amount of time to
supply additional information demonstrating compliance with
requirements of this Section and to request a hearing. The

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hearing notice shall be sent by certified mail, return receipt
requested, and the hearing shall be conducted in accordance
with the Illinois Administrative Procedure Act.
(g) A utilization review program subject to a corrective
action may continue to conduct business until a final decision
has been issued by the Department.
(h) Any adverse determination made by a health carrier care
plan or its subcontractors may be appealed in accordance with
the Health Carrier Grievance Procedure Law subsection (f) of
Section 45.
(i) The Director may by rule establish a registration fee
for each person conducting a utilization review program. All
fees paid to and collected by the Director under this Section
shall be deposited into the Insurance Producer Administration
Fund.
(Source: P.A. 91-617, eff. 7-1-00.)
Section 90-10. The Health Carrier External Review Act is
amended by changing Sections 10, 20, 25, 30, 35, 40, 55, 65,
and 75 and by adding Sections 42 and 80 as follows:
(215 ILCS 180/10)
Sec. 10. Definitions. For the purposes of this Act:
"Adverse determination" has the same meaning given that
term in the Health Carrier Grievance Procedure Law means a
determination by a health carrier or its designee utilization

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review organization that an admission, availability of care,
continued stay, or other health care service that is a covered
benefit has been reviewed and, based upon the information
provided, does not meet the health carrier's requirements for
medical necessity, appropriateness, health care setting, level
of care, or effectiveness, and the requested service or payment
for the service is therefore denied, reduced, or terminated.
"Authorized representative" has the same meaning given
that term in the Health Carrier Grievance Procedure Law. means:
(1) a person to whom a covered person has given express
written consent to represent the covered person in an
external review, including the covered person's health
care provider;
(2) a person authorized by law to provide substituted
consent for a covered person; or
(3) the covered person's health care provider when the
covered person is unable to provide consent.
"Best evidence" means evidence based on:
(1) randomized clinical trials;
(2) if randomized clinical trials are not available,
then cohort studies or case-control studies;
(3) if items (1) and (2) are not available, then
case-series; or
(4) if items (1), (2), and (3) are not available, then
expert opinion.
"Case-series" means an evaluation of a series of patients

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with a particular outcome, without the use of a control group.
"Clinical review criteria" has the same meaning given that
term in the Health Carrier Grievance Procedure Law means the
written screening procedures, decision abstracts, clinical
protocols, and practice guidelines used by a health carrier to
determine the necessity and appropriateness of health care
services.
"Cohort study" means a prospective evaluation of 2 groups
of patients with only one group of patients receiving specific
intervention.
"Covered benefits" or "benefits" has the same meaning given
that term in the Health Carrier Grievance Procedure Law means
those health care services to which a covered person is
entitled under the terms of a health benefit plan.
"Covered person" has the same meaning given that term in
the Health Carrier Grievance Procedure Law means a
policyholder, subscriber, enrollee, or other individual
participating in a health benefit plan.
"Director" means the Director of the Department of
Insurance.
"Emergency medical condition" has the same meaning given
that term in the Health Carrier Grievance Procedure Law. means
a medical condition manifesting itself by acute symptoms of
sufficient severity, including, but not limited to, severe
pain, such that a prudent layperson who possesses an average
knowledge of health and medicine could reasonably expect the

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absence of immediate medical attention to result in:
(1) placing the health of the individual or, with
respect to a pregnant woman, the health of the woman or her
unborn child, in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
"Emergency services" has the same meaning given that term
in the Health Carrier Grievance Procedure Law means health care
items and services furnished or required to evaluate and treat
an emergency medical condition.
"Evidence-based standard" means the conscientious,
explicit, and judicious use of the current best evidence based
on an overall systematic review of the research in making
decisions about the care of individual patients.
"Expert opinion" means a belief or an interpretation by
specialists with experience in a specific area about the
scientific evidence pertaining to a particular service,
intervention, or therapy.
"Facility" has the same meaning given that term in the
Health Carrier Grievance Procedure Law means an institution
providing health care services or a health care setting.
"Final adverse determination" has the same meaning given
that term in the Health Carrier Grievance Procedure Law means
an adverse determination involving a covered benefit that has
been upheld by a health carrier, or its designee utilization
review organization, at the completion of the health carrier's

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internal grievance process procedures as set forth by the
Managed Care Reform and Patient Rights Act.
"Health benefit plan" has the same meaning given that term
in the Health Carrier Grievance Procedure Law means a policy,
contract, certificate, plan, or agreement offered or issued by
a health carrier to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services.
"Health care professional" has the same meaning given that
term in the Health Carrier Grievance Procedure Law.
"Health care provider" or "provider" has the same meaning
given that term in the Health Carrier Grievance Procedure Law
means a physician, hospital facility, or other health care
practitioner licensed, accredited, or certified to perform
specified health care services consistent with State law,
responsible for recommending health care services on behalf of
a covered person.
"Health care services" has the same meaning given that term
in the Health Carrier Grievance Procedure Law means services
for the diagnosis, prevention, treatment, cure, or relief of a
health condition, illness, injury, or disease.
"Health carrier" has the same meaning given that term in
the Health Carrier Grievance Procedure Law means an entity
subject to the insurance laws and regulations of this State, or
subject to the jurisdiction of the Director, that contracts or
offers to contract to provide, deliver, arrange for, pay for,
or reimburse any of the costs of health care services,

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including a sickness and accident insurance company, a health
maintenance organization, or any other entity providing a plan
of health insurance, health benefits, or health care services.
"Health carrier" also means Limited Health Service
Organizations (LHSO) and Voluntary Health Service Plans.
"Health information" means information or data, whether
oral or recorded in any form or medium, and personal facts or
information about events or relationships that relate to:
(1) the past, present, or future physical, mental, or
behavioral health or condition of an individual or a member
of the individual's family;
(2) the provision of health care services to an
individual; or
(3) payment for the provision of health care services
to an individual.
"Independent review organization" means an entity that
conducts independent external reviews of adverse
determinations and final adverse determinations.
"Medical or scientific evidence" means evidence found in
the following sources:
(1) peer-reviewed scientific studies published in or
accepted for publication by medical journals that meet
nationally recognized requirements for scientific
manuscripts and that submit most of their published
articles for review by experts who are not part of the
editorial staff;

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(2) peer-reviewed medical literature, including
literature relating to therapies reviewed and approved by a
qualified institutional review board, biomedical
compendia, and other medical literature that meet the
criteria of the National Institutes of Health's Library of
Medicine for indexing in Index Medicus (Medline) and
Elsevier Science Ltd. for indexing in Excerpta Medicus
(EMBASE);
(3) medical journals recognized by the Secretary of
Health and Human Services under Section 1861(t)(2) of the
federal Social Security Act;
(4) the following standard reference compendia:
(a) The American Hospital Formulary Service-Drug
Information;
(b) Drug Facts and Comparisons;
(c) The American Dental Association Accepted
Dental Therapeutics; and
(d) The United States Pharmacopoeia-Drug
Information;
(5) findings, studies, or research conducted by or
under the auspices of federal government agencies and
nationally recognized federal research institutes,
including:
(a) the federal Agency for Healthcare Research and
Quality;
(b) the National Institutes of Health;

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(c) the National Cancer Institute;
(d) the National Academy of Sciences;
(e) the Centers for Medicare & Medicaid Services;
(f) the federal Food and Drug Administration; and
(g) any national board recognized by the National
Institutes of Health for the purpose of evaluating the
medical value of health care services; or
(6) any other medical or scientific evidence that is
comparable to the sources listed in items (1) through (5).
"Person" has the same meaning given that term in the Health
Carrier Grievance Procedure Law.
"Protected health information" means health information
(i) that identifies an individual who is the subject of the
information; or (ii) with respect to which there is a
reasonable basis to believe that the information could be used
to identify an individual.
"Randomized clinical trial" means a controlled prospective
study of patients that have been randomized into an
experimental group and a control group at the beginning of the
study with only the experimental group of patients receiving a
specific intervention, which includes study of the groups for
variables and anticipated outcomes over time.
"Retrospective review" has the same meaning given that term
in the Health Carrier Grievance Procedure Law means a review of
medical necessity conducted after services have been provided
to a patient, but does not include the review of a claim that

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is limited to an evaluation of reimbursement levels, veracity
of documentation, accuracy of coding, or adjudication for
payment.
"Utilization review" has the meaning provided by the
Managed Care Reform and Patient Rights Act.
"Utilization review organization" means a utilization
review program as defined in the Managed Care Reform and
Patient Rights Act.
(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/20)
Sec. 20. Notice of right to external review.
(a) At the same time the health carrier sends written
notice of a covered person's right to appeal a coverage
decision upon an adverse determination or a final adverse
determination as provided by the Managed Care Reform and
Patient Rights Act, a health carrier shall notify a covered
person, the covered person's authorized representative, if
any, and a covered person's health care provider in writing of
the covered person's right to request an external review as
provided by this Act. The written notice required shall include
the following, or substantially equivalent, language: "We have
denied your request for the provision of or payment for a
health care service or course of treatment. You have the right
to have our decision reviewed by an independent review
organization not associated with us if our decision involved

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making a judgment as to the medical necessity, appropriateness,
health care setting, level of care, or effectiveness of the
health care service or treatment you requested by submitting a
written request for an external review to the Department of
Insurance, Office of Consumer Health Information, 320 West
Washington Street, 4th Floor, Springfield, Illinois, 62767."
us. Upon receipt of your request an independent review
organization registered with the Department of Insurance will
be assigned to review our decision.
(a-5) The Department may prescribe the form and content of
the notice required under this Section.
(b) This subsection (b) shall apply to an expedited review
prior to a final adverse determination. In addition to the
notice required in subsection (a), for the health carrier shall
include a notice related to an adverse determination, the
health carrier shall include a statement informing the covered
person of all of the following:
(1) If the covered person has a medical condition where
the timeframe for completion of (A) an expedited internal
review of an appeal a grievance involving an adverse
determination, (B) a final adverse determination as set
forth in the Managed Care Reform and Patient Rights Act, or
(C) a standard external review as established in this Act,
would seriously jeopardize the life or health of the
covered person or would jeopardize the covered person's
ability to regain maximum function, then the covered person

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or the covered person's authorized representative may file
a request for an expedited external review.
(2) The covered person or the covered person's
authorized representative may file an appeal under the
health carrier's internal appeal process as set forth in
the Health Carrier Grievance Procedure Law, but if the
health carrier has not issued a written decision to the
covered person or the covered person's authorized
representative 30 days following the date the covered
person or the covered person's authorized representative
files an appeal of an adverse determination that involves a
prospective review request or 60 days following the date
the covered person or the covered person's authorized
representative files an appeal of an adverse determination
that involves a retrospective review request with the
health carrier and the covered person or the covered
person's authorized representative has not requested or
agreed to a delay, then the covered person or the covered
person's authorized representative may file a request for
external review and shall be considered to have exhausted
the health carrier's internal appeal process for purposes
of this Act. The covered person or the covered person's
authorized representative may file a request for an
expedited external review at the same time the covered
person or the covered person's authorized representative
files a request for an expedited internal appeal involving

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an adverse determination as set forth in the Managed Care
Reform and Patient Rights Act if the adverse determination
involves a denial of coverage based on a determination that
the recommended or requested health care service or
treatment is experimental or investigational and the
covered person's health care provider certifies in writing
that the recommended or requested health care service or
treatment that is the subject of the adverse determination
would be significantly less effective if not promptly
initiated. The independent review organization assigned to
conduct the expedited external review will determine
whether the covered person shall be required to complete
the expedited review of the grievance prior to conducting
the expedited external review.
(3) The covered person or the covered person's
authorized representative filed a request for an expedited
internal review of an adverse determination pursuant to the
Health Carrier Grievance Procedure Law and has not received
a decision on such request from the health carrier within
48 hours, except to the extent the covered person or the
covered person's authorized representative requested or
agreed to a delay.
(4) (3) If an adverse determination concerns a denial
of coverage based on a determination that the recommended
or requested health care service or treatment is
experimental or investigational and the covered person's

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health care provider certifies in writing that the
recommended or requested health care service or treatment
that is the subject of the request would be significantly
less effective if not promptly initiated, then the covered
person or the covered person's authorized representative
may request an expedited external review at the same time
the covered person or the covered person's authorized
representative files a request for an expedited internal
appeal involving an adverse determination as set forth in
the Health Carrier Grievance Procedure Law. The
independent review organization assigned to conduct the
expedited external review shall determine whether the
covered person is required to complete the expedited review
of the appeal prior to conducting the expedited external
review.
(c) This subsection (c) shall apply to an expedited review
upon final adverse determination. In addition to the notice
required in subsection (a), for the health carrier shall
include a notice related to a final adverse determination, the
health carrier shall include a statement informing the covered
person of all of the following:
(1) if the covered person has a medical condition where
the timeframe for completion of a standard external review
would seriously jeopardize the life or health of the
covered person or would jeopardize the covered person's
ability to regain maximum function, then the covered person

HB0224 Engrossed - 90 - LRB097 05693 RPM 45756 b
or the covered person's authorized representative may file
a request for an expedited external review; or
(2) if a final adverse determination concerns an
admission, availability of care, continued stay, or health
care service for which the covered person received
emergency services, but has not been discharged from a
facility, then the covered person, or the covered person's
authorized representative, may request an expedited
external review; or
(3) if a final adverse determination concerns a denial
of coverage based on a determination that the recommended
or requested health care service or treatment is
experimental or investigational, and the covered person's
health care provider certifies in writing that the
recommended or requested health care service or treatment
that is the subject of the request would be significantly
less effective if not promptly initiated, then the covered
person or the covered person's authorized representative
may request an expedited external review.
(d) In addition to the information to be provided pursuant
to subsections (a), (b), and (c) of this Section, the health
carrier shall include a copy of the description of both the
required standard and expedited external review procedures.
The description shall highlight the external review procedures
that give the covered person or the covered person's authorized
representative the opportunity to submit additional

HB0224 Engrossed - 91 - LRB097 05693 RPM 45756 b
information, including any forms used to process an external
review.
(e) As part of any forms provided under subsection (d) of
this Section, the health carrier shall include an authorization
form, or other document approved by the Director, by which the
covered person, for purposes of conducting an external review
under this Act, authorizes the health carrier and the covered
person's treating health care provider to disclose protected
health information, including medical records, concerning the
covered person that is pertinent to the external review, as
provided in the Illinois Insurance Code.
(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/25)
Sec. 25. Request for external review. A covered person or
the covered person's authorized representative may make a
request for a standard external or expedited external review of
an adverse determination or final adverse determination.
Except as set forth in Sections 40 and 42 of this Act, all
requests for external review Requests under this Section shall
be made in writing to the Director directly to the health
carrier that made the adverse or final adverse determination.
All requests for external review shall be in writing except for
requests for expedited external reviews which may me made
orally. Health carriers must provide covered persons with forms
to request external reviews.

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(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/30)
Sec. 30. Exhaustion of internal appeal grievance process.
(a) Except as provided in subsection (b) of this Section
20, a request for an external review shall not be made until
the covered person has exhausted the health carrier's internal
appeal grievance process as set forth in the Health Carrier
Grievance Procedure Law Managed Care Reform and Patient Rights
Act.
(b) A covered person shall also be considered to have
exhausted the health carrier's internal appeal grievance
process for purposes of this Section if:
(1) the covered person or the covered person's
authorized representative has filed an appeal under the
health carrier's internal appeal process as set forth in a
request for an internal review of an adverse determination
pursuant to the Health Carrier Grievance Procedure Law
Managed Care Reform and Patient Rights Act and has not
received a written decision on the appeal 30 days following
the date the covered person or the covered person's
authorized representative files an appeal of an adverse
determination that involves a prospective review request
or 60 days following the date the covered person or the
covered person's authorized representative files an appeal
of an adverse determination that involves a retrospective

HB0224 Engrossed - 93 - LRB097 05693 RPM 45756 b
review request request from the health carrier within 15
days after receipt of the required information but not more
than 30 days after the request was filed by the covered
person or the covered person's authorized representative,
except to the extent the covered person or the covered
person's authorized representative requested or agreed to
a delay; however, a covered person or the covered person's
authorized representative may not make a request for an
external review of an adverse determination involving a
retrospective review determination until the covered
person has exhausted the health carrier's internal
grievance process;
(2) the covered person or the covered person's
authorized representative filed a request for an expedited
internal review of an adverse determination pursuant to the
Health Carrier Grievance Procedure Law Managed Care Reform
and Patient Rights Act and has not received a decision on
such request from the health carrier within 48 hours,
except to the extent the covered person or the covered
person's authorized representative requested or agreed to
a delay; or
(3) the health carrier agrees to waive the exhaustion
requirement; .
(4) the covered person has a medical condition in which
the timeframe for completion of (A) an expedited internal
review of a appeal involving an adverse determination, (B)

HB0224 Engrossed - 94 - LRB097 05693 RPM 45756 b
a final adverse determination, or (C) a standard external
review as established in this Act would seriously
jeopardize the life or health of the covered person or
would jeopardize the covered person's ability to regain
maximum function;
(5) an adverse determination concerns a denial of
coverage based on a determination that the recommended or
requested health care service or treatment is experimental
or investigational and the covered person's health care
provider certifies in writing that the recommended or
requested health care service or treatment that is the
subject of the request would be significantly less
effective if not promptly initiated; in such cases, the
covered person or the covered person's authorized
representative may request an expedited external review at
the same time the covered person or the covered person's
authorized representative files a request for an expedited
internal appeal involving an adverse determination as set
forth in the Health Carrier Grievance Procedure Law; the
independent review organization assigned to conduct the
expedited external review shall determine whether the
covered person is required to complete the expedited review
of the appeal prior to conducting the expedited external
review; or
(6) the health carrier has failed to comply with
Section 5-40 or 5-45 of the Utilization Review and Benefit

HB0224 Engrossed - 95 - LRB097 05693 RPM 45756 b
Determination Law, as set forth in subsection (d) of
Section 5-35 of that Law, or Section 10-30 or 10-40 of the
Health Carrier Grievance Procedure Law, as set forth in
subsection (b) of Section 10-25 of that Law.
(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/35)
Sec. 35. Standard external review.
(a) Within 4 months after the date of receipt of a notice
of an adverse determination or final adverse determination, a
covered person or the covered person's authorized
representative may file a request for an external review with
the Director. Within one business day after the date of receipt
of a request for external review, the Director shall send a
copy of the request to the health carrier.
(b) Within 5 business days following the date of receipt of
the external review request, the health carrier shall complete
a preliminary review of the request to determine whether:
(1) the individual is or was a covered person in the
health benefit plan at the time the health care service was
requested or at the time the health care service was
provided;
(2) the health care service that is the subject of the
adverse determination or the final adverse determination
is a covered service under the covered person's health
benefit plan, but the health carrier has determined that

HB0224 Engrossed - 96 - LRB097 05693 RPM 45756 b
the health care service is not covered because it does not
meet the health carrier's requirements for medical
necessity, appropriateness, health care setting, level of
care, or effectiveness;
(3) the covered person has exhausted the health
carrier's internal appeal grievance process as set forth in
the Health Carrier Grievance Procedure Act unless the
covered person is not required to exhaust the health
carrier's internal appeal process pursuant to this Act;
(4) (blank); and for appeals relating to a
determination based on treatment being experimental or
investigational, the requested health care service or
treatment that is the subject of the adverse determination
or final adverse determination is a covered benefit under
the covered person's health benefit plan except for the
health carrier's determination that the service or
treatment is experimental or investigational for a
particular medical condition and is not explicitly listed
as an excluded benefit under the covered person's health
benefit plan with the health carrier and that the covered
person's health care provider, who ordered or provided the
services in question and who is licensed under the Medical
Practice Act of 1987, has certified that one of the
following situations is applicable:
(A) standard health care services or treatments
have not been effective in improving the condition of

HB0224 Engrossed - 97 - LRB097 05693 RPM 45756 b
the covered person;
(B) standard health care services or treatments
are not medically appropriate for the covered person;
(C) there is no available standard health care
service or treatment covered by the health carrier that
is more beneficial than the recommended or requested
health care service or treatment;
(D) the health care service or treatment is likely
to be more beneficial to the covered person, in the
health care provider's opinion, than any available
standard health care services or treatments; or
(E) that scientifically valid studies using
accepted protocols demonstrate that the health care
service or treatment requested is likely to be more
beneficial to the covered person than any available
standard health care services or treatments; and
(5) the covered person has provided all the information
and forms required to process an external review, as
specified in this Act.
(c) Within one business day after completion of the
preliminary review, the health carrier shall notify the
Director and covered person and, if applicable, the covered
person's authorized representative in writing whether the
request is complete and eligible for external review. If the
request:
(1) is not complete, the health carrier shall inform

HB0224 Engrossed - 98 - LRB097 05693 RPM 45756 b
the Director and covered person and, if applicable, the
covered person's authorized representative in writing and
include in the notice what information or materials are
required by this Act to make the request complete; or
(2) is not eligible for external review, the health
carrier shall inform the Director and covered person and,
if applicable, the covered person's authorized
representative in writing and include in the notice the
reasons for its ineligibility.
The Department may specify the form for the health
carrier's notice of initial determination under this
subsection (c) and any supporting information to be included in
the notice.
The notice of initial determination of ineligibility shall
include a statement informing the covered person and, if
applicable, the covered person's authorized representative
that a health carrier's initial determination that the external
review request is ineligible for review may be appealed to the
Director by filing a complaint with the Director.
Notwithstanding a health carrier's initial determination
that the request is ineligible for external review, the
Director may determine that a request is eligible for external
review and require that it be referred for external review. In
making such determination, the Director's decision shall be in
accordance with the terms of the covered person's health
benefit plan, unless such terms are inconsistent with

HB0224 Engrossed - 99 - LRB097 05693 RPM 45756 b
applicable law, and shall be subject to all applicable
provisions of this Act.
(d) Whenever the Director receives notice that a request is
eligible for external review following the preliminary review
conducted pursuant to this Section the health carrier shall,
within one 5 business day after the date of receipt of the
notice, the Director shall days:
(1) assign an independent review organization from the
list of approved independent review organizations compiled
and maintained by the Director pursuant to this Act and
notify the health carrier of the name of the assigned
independent review organization; and
(2) notify in writing the covered person and, if
applicable, the covered person's authorized representative
of the request's eligibility and acceptance for external
review and the name of the independent review organization.
The Director health carrier shall include in the notice
provided to the covered person and, if applicable, the covered
person's authorized representative a statement that the
covered person or the covered person's authorized
representative may, within 5 business days following the date
of receipt of the notice provided pursuant to item (2) of this
subsection (d), submit in writing to the assigned independent
review organization additional information that the
independent review organization shall consider when conducting
the external review. The independent review organization is not

HB0224 Engrossed - 100 - LRB097 05693 RPM 45756 b
required to, but may, accept and consider additional
information submitted after 5 business days.
(e) The assignment by the Director of an approved
independent review organization to conduct an external review
in accordance with this Section shall be done on a random basis
among those independent review organizations approved by the
Director pursuant to this Act. The assignment of an approved
independent review organization to conduct an external review
in accordance with this Section shall be made from those
approved independent review organizations qualified to conduct
external review as required by Sections 50 and 55 of this Act.
(f) Within Upon assignment of an independent review
organization, the health carrier or its designee utilization
review organization shall, within 5 business days after the
date of receipt of the notice provided pursuant to item (1) of
subsection (d) of this Section, the health carrier or its
designee utilization review organization shall provide to the
assigned independent review organization the documents and any
information considered in making the adverse determination or
final adverse determination; in such cases, the following
provisions shall apply:
(1) Except as provided in item (2) of this subsection
(f), failure by the health carrier or its utilization
review organization to provide the documents and
information within the specified time frame shall not delay
the conduct of the external review.

HB0224 Engrossed - 101 - LRB097 05693 RPM 45756 b
(2) If the health carrier or its utilization review
organization fails to provide the documents and
information within the specified time frame, the assigned
independent review organization may terminate the external
review and make a decision to reverse the adverse
determination or final adverse determination.
(3) Within one business day after making the decision
to terminate the external review and make a decision to
reverse the adverse determination or final adverse
determination under item (2) of this subsection (f), the
independent review organization shall notify the Director,
the health carrier, the covered person and, if applicable,
the covered person's authorized representative, of its
decision to reverse the adverse determination.
(g) Upon receipt of the information from the health carrier
or its utilization review organization, the assigned
independent review organization shall review all of the
information and documents and any other information submitted
in writing to the independent review organization by the
covered person and the covered person's authorized
representative.
(h) Upon receipt of any information submitted by the
covered person or the covered person's authorized
representative, the independent review organization shall
forward the information to the health carrier within 1 business
day.

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(1) Upon receipt of the information, if any, the health
carrier may reconsider its adverse determination or final
adverse determination that is the subject of the external
review.
(2) Reconsideration by the health carrier of its
adverse determination or final adverse determination shall
not delay or terminate the external review.
(3) The external review may only be terminated if the
health carrier decides, upon completion of its
reconsideration, to reverse its adverse determination or
final adverse determination and provide coverage or
payment for the health care service that is the subject of
the adverse determination or final adverse determination.
In such cases, the following provisions shall apply:
(A) Within one business day after making the
decision to reverse its adverse determination or final
adverse determination, the health carrier shall notify
the Director, the covered person and, if applicable,
the covered person's authorized representative, and
the assigned independent review organization in
writing of its decision.
(B) Upon notice from the health carrier that the
health carrier has made a decision to reverse its
adverse determination or final adverse determination,
the assigned independent review organization shall
terminate the external review.

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(i) In addition to the documents and information provided
by the health carrier or its utilization review organization
and the covered person and the covered person's authorized
representative, if any, the independent review organization,
to the extent the information or documents are available and
the independent review organization considers them
appropriate, shall consider the following in reaching a
decision:
(1) the covered person's pertinent medical records;
(2) the covered person's health care provider's
recommendation;
(3) consulting reports from appropriate health care
providers and other documents submitted by the health
carrier or its designee utilization review organization,
the covered person, the covered person's authorized
representative, or the covered person's treating provider;
(4) the terms of coverage under the covered person's
health benefit plan with the health carrier to ensure that
the independent review organization's decision is not
contrary to the terms of coverage under the covered
person's health benefit plan with the health carrier,
unless the terms are inconsistent with applicable law;
(5) the most appropriate practice guidelines, which
shall include applicable evidence-based standards and may
include any other practice guidelines developed by the
federal government, national or professional medical

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societies, boards, and associations;
(6) any applicable clinical review criteria developed
and used by the health carrier or its designee utilization
review organization; and
(7) the opinion of the independent review
organization's clinical reviewer or reviewers after
considering items (1) through (6) of this subsection (i) to
the extent the information or documents are available and
the clinical reviewer or reviewers considers the
information or documents appropriate; and
(8) (blank). for a denial of coverage based on a
determination that the health care service or treatment
recommended or requested is experimental or
investigational, whether and to what extent:
(A) the recommended or requested health care
service or treatment has been approved by the federal
Food and Drug Administration, if applicable, for the
condition;
(B) medical or scientific evidence or
evidence-based standards demonstrate that the expected
benefits of the recommended or requested health care
service or treatment is more likely than not to be
beneficial to the covered person than any available
standard health care service or treatment and the
adverse risks of the recommended or requested health
care service or treatment would not be substantially

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increased over those of available standard health care
services or treatments; or
(C) the terms of coverage under the covered
person's health benefit plan with the health carrier to
ensure that the health care service or treatment that
is the subject of the opinion is experimental or
investigational would otherwise be covered under the
terms of coverage of the covered person's health
benefit plan with the health carrier.
(j) Within 5 days after the date of receipt of all
necessary information, but in no event more than 45 days after
the date of receipt of the request for an external review, the
assigned independent review organization shall provide written
notice of its decision to uphold or reverse the adverse
determination or the final adverse determination to the
Director, the health carrier, the covered person, and, if
applicable, the covered person's authorized representative. In
reaching a decision, the assigned independent review
organization is not bound by any claim determinations reached
prior to the submission of information to the independent
review organization. In such cases, the following provisions
shall apply:
(1) The independent review organization shall include
in the notice:
(A) a general description of the reason for the
request for external review;

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(B) the date the independent review organization
received the assignment from the Director health
carrier to conduct the external review;
(C) the time period during which the external
review was conducted;
(D) references to the evidence or documentation,
including the evidence-based standards, considered in
reaching its decision;
(E) the date of its decision; and
(F) the principal reason or reasons for its
decision, including what applicable, if any,
evidence-based standards that were a basis for its
decision; and .
(G) the rationale for its decision.
(2) (Blank). For reviews of experimental or
investigational treatments, the notice shall include the
following information:
(A) a description of the covered person's medical
condition;
(B) a description of the indicators relevant to
whether there is sufficient evidence to demonstrate
that the recommended or requested health care service
or treatment is more likely than not to be more
beneficial to the covered person than any available
standard health care services or treatments and the
adverse risks of the recommended or requested health

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care service or treatment would not be substantially
increased over those of available standard health care
services or treatments;
(C) a description and analysis of any medical or
scientific evidence considered in reaching the
opinion;
(D) a description and analysis of any
evidence-based standards;
(E) whether the recommended or requested health
care service or treatment has been approved by the
federal Food and Drug Administration, for the
condition;
(F) whether medical or scientific evidence or
evidence-based standards demonstrate that the expected
benefits of the recommended or requested health care
service or treatment is more likely than not to be more
beneficial to the covered person than any available
standard health care service or treatment and the
adverse risks of the recommended or requested health
care service or treatment would not be substantially
increased over those of available standard health care
services or treatments; and
(G) the written opinion of the clinical reviewer,
including the reviewer's recommendation as to whether
the recommended or requested health care service or
treatment should be covered and the rationale for the

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reviewer's recommendation.
(3) (Blank). In reaching a decision, the assigned
independent review organization is not bound by any
decisions or conclusions reached during the health
carrier's utilization review process or the health
carrier's internal grievance or appeals process.
(4) Upon receipt of a notice of a decision reversing
the adverse determination or final adverse determination,
the health carrier immediately shall approve the coverage
that was the subject of the adverse determination or final
adverse determination.
(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)
(215 ILCS 180/40)
Sec. 40. Expedited external review.
(a) A covered person or a covered person's authorized
representative may file a request for an expedited external
review with the Director health carrier either orally or in
writing:
(1) immediately after the date of receipt of a notice
prior to a final adverse determination as provided by
subsection (b) of Section 20 of this Act;
(2) immediately after the date of receipt of a notice
upon a final adverse determination as provided by
subsection (c) of Section 20 of this Act; or
(3) if a health carrier fails to provide a decision on

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request for an expedited internal appeal within 48 hours as
provided by item (2) of Section 30 of this Act.
(b) Upon receipt of a request for an expedited external
review, the Director shall immediately send a copy of the
request to the health carrier. Immediately upon receipt of the
request for an expedited external review as provided under
subsections (b) and (c) of Section 20, the health carrier shall
determine whether the request meets the reviewability
requirements set forth in items (1), (2), and (4) of subsection
(b) of Section 35. In such cases, the following provisions
shall apply:
(1) The health carrier shall immediately notify the
Director, the covered person, and, if applicable, the
covered person's authorized representative of its
eligibility determination.
(2) The notice of initial determination shall include a
statement informing the covered person and, if applicable,
the covered person's authorized representative that a
health carrier's initial determination that an external
review request is ineligible for review may be appealed to
the Director.
(3) The Director may determine that a request is
eligible for expedited external review notwithstanding a
health carrier's initial determination that the request is
ineligible and require that it be referred for external
review.

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(4) In making a determination under item (3) of this
subsection (b), the Director's decision shall be made in
accordance with the terms of the covered person's health
benefit plan, unless such terms are inconsistent with
applicable law, and shall be subject to all applicable
provisions of this Act.
(5) The Director may specify the form for the health
carrier's notice of initial determination under this
subsection (b) and any supporting information to be
included in the notice.
(c) Upon receipt of the notice that the request meets the
reviewability requirements, determining that a request meets
the requirements of subsections (b) and (c) of Section 20, the
Director health carrier shall immediately assign an
independent review organization from the list of approved
independent review organizations compiled and maintained by
the Director to conduct the expedited review. In such cases,
the following provisions shall apply:
(1) The assignment of an approved independent review
organization to conduct an external review in accordance
with this Section shall be made from those approved
independent review organizations qualified to conduct
external review as required by Sections 50 and 55 of this
Act.
(2) The Director shall immediately notify the health
carrier of the name of the assigned independent review

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organization. Immediately upon receipt from the Director
of the name of the independent review organization assigned
to conduct the external review assigning an independent
review organization to perform an expedited external
review, but in no case more than 24 hours after receiving
such notice assigning the independent review organization,
the health carrier or its designee utilization review
organization shall provide or transmit all necessary
documents and information considered in making the adverse
determination or final adverse determination to the
assigned independent review organization electronically or
by telephone or facsimile or any other available
expeditious method.
(3) If the health carrier or its utilization review
organization fails to provide the documents and
information within the specified timeframe, the assigned
independent review organization may terminate the external
review and make a decision to reverse the adverse
determination or final adverse determination.
(4) Within one business day after making the decision
to terminate the external review and make a decision to
reverse the adverse determination or final adverse
determination under item (3) of this subsection (c), the
independent review organization shall notify the Director,
the health carrier, the covered person, and, if applicable,
the covered person's authorized representative of its

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decision to reverse the adverse determination or final
adverse determination.
(d) In addition to the documents and information provided
by the health carrier or its utilization review organization
and any documents and information provided by the covered
person and the covered person's authorized representative, the
independent review organization, to the extent the information
or documents are available and the independent review
organization considers them appropriate, shall consider
information as required by subsection (i) of Section 35 of this
Act in reaching a decision.
(e) As expeditiously as the covered person's medical
condition or circumstances requires, but in no event more than
72 hours after the date of receipt of the request for an
expedited external review 2 business days after the receipt of
all pertinent information, the assigned independent review
organization shall:
(1) make a decision to uphold or reverse the final
adverse determination; and
(2) notify the Director, the health carrier, the
covered person, the covered person's health care provider,
and, if applicable, the covered person's authorized
representative, of the decision.
(f) In reaching a decision, the assigned independent review
organization is not bound by any decisions or conclusions
reached during the health carrier's utilization review process

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or the health carrier's internal appeal grievance process as
set forth in the Health Carrier Grievance Procedure Law Managed
Care Reform and Patient Rights Act.
(g) Upon receipt of notice of a decision reversing the
adverse determination or final adverse determination, the
health carrier shall immediately approve the coverage that was
the subject of the adverse determination or final adverse
determination.
(h) If the notice provided pursuant to subsection (e) of
this Section was not in writing, then within Within 48 hours
after the date of providing that the notice required in item
(2) of subsection (e), the assigned independent review
organization shall provide written confirmation of the
decision to the Director, the health carrier, the covered
person, and, if applicable, the covered person's authorized
representative including the information set forth in
subsection (j) of Section 35 of this Act as applicable.
(i) An expedited external review may not be provided for
retrospective adverse or final adverse determinations.
(j) The assignment by the Director of an approved
independent review organization to conduct an external review
in accordance with this Section shall be done on a random basis
among those independent review organizations approved by the
Director pursuant to this Act.
(Source: P.A. 96-857, eff. 7-1-10; revised 9-16-10.)

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(215 ILCS 180/42 new)
Sec. 42. External review of experimental or
investigational treatment adverse determinations.
(a) Within 4 months after the date of receipt of a notice
of an adverse determination or final adverse determination that
involves a denial of coverage based on a determination that the
health care service or treatment recommended or requested is
experimental or investigational, a covered person or the
covered person's authorized representative may file a request
for an external review with the Director.
(b) The following provisions apply to cases concerning
expedited external reviews:
(1) A covered person or the covered person's authorized
representative may make an oral request for an expedited
external review of the adverse determination or final
adverse determination pursuant to subsection (a) of this
Section if the covered person's treating physician
certifies, in writing, that the recommended or requested
health care service or treatment that is the subject of the
request would be significantly less effective if not
promptly initiated.
(2) Upon receipt of a request for an expedited external
review, the Director shall immediately notify the health
carrier.
(3) The following provisions apply concerning notice:
(A) Upon notice of the request for an expedited

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external review, the health carrier shall immediately
determine whether the request meets the reviewability
requirements of subsection (d) of this Section. The
health carrier shall immediately notify the Director
and the covered person and, if applicable, the covered
person's authorized representative of its eligibility
determination.
(B) The Director may specify the form for the
health carrier's notice of initial determination under
subdivision (A) of this item (3) and any supporting
information to be included in the notice.
(C) The notice of initial determination under
subdivision (A) of this item (3) shall include a
statement informing the covered person and, if
applicable, the covered person's authorized
representative that a health carrier's initial
determination that the external review request is
ineligible for review may be appealed to the Director.
(4) The following provisions apply concerning the
Director's determination:
(A) The Director may determine that a request is
eligible for external review under subsection (d) of
this Section notwithstanding a health carrier's
initial determination that the request is ineligible
and require that it be referred for external review.
(B) In making a determination under subdivision

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(A) of this item (4), the Director's decision shall be
made in accordance with the terms of the covered
person's health benefit plan, unless such terms are
inconsistent with applicable law, and shall be subject
to all applicable provisions of this Act.
(5) Upon receipt of the notice that the expedited
external review request meets the reviewability
requirements of subsection (d) of this Section, the
Director shall immediately assign an independent review
organization to review the expedited request from the list
of approved independent review organizations compiled and
maintained by the Director and notify the health carrier of
the name of the assigned independent review organization.
(6) At the time the health carrier receives the notice
of the assigned independent review organization, the
health carrier or its designee utilization review
organization shall provide or transmit all necessary
documents and information considered in making the adverse
determination or final adverse determination to the
assigned independent review organization electronically or
by telephone or facsimile or any other available
expeditious method.
(c) Except for a request for an expedited external review
made pursuant to subsection (b) of this Section, within one
business day after the date of receipt of a request for
external review, the Director shall send a copy of the request

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to the health carrier.
(d) Within 5 business days following the date of receipt of
the external review request, the health carrier shall complete
a preliminary review of the request to determine whether:
(1) the individual is or was a covered person in the
health benefit plan at the time the health care service was
recommended or requested or, in the case of a retrospective
review, at the time the health care service was provided;
(2) the recommended or requested health care service or
treatment that is the subject of the adverse determination
or final adverse determination is a covered benefit under
the covered person's health benefit plan except for the
health carrier's determination that the service or
treatment is experimental or investigational for a
particular medical condition and is not explicitly listed
as an excluded benefit under the covered person's health
benefit plan with the health carrier;
(3) the covered person's health care provider has
certified that one of the following situations is
applicable:
(A) standard health care services or treatments
have not been effective in improving the condition of
the covered person;
(B) standard health care services or treatments
are not medically appropriate for the covered person;
or

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(C) there is no available standard health care
service or treatment covered by the health carrier that
is more beneficial than the recommended or requested
health care service or treatment;
(4) the covered person's health care provider:
(A) has recommended a health care service or
treatment that the physician certifies, in writing, is
likely to be more beneficial to the covered person, in
the physician's opinion, than any available standard
health care services or treatments; or
(B) who is a licensed, board certified or board
eligible physician qualified to practice in the area of
medicine appropriate to treat the covered person's
condition, has certified in writing that
scientifically valid studies using accepted protocols
demonstrate that the health care service or treatment
requested by the covered person that is the subject of
the adverse determination or final adverse
determination is likely to be more beneficial to the
covered person than any available standard health care
services or treatments;
(5) the covered person has exhausted the health
carrier's internal appeal process as set forth in the
Health Carrier Grievance Procedure Act, unless the covered
person is not required to exhaust the health carrier's
internal appeal process pursuant to Section 30 of this Act;

HB0224 Engrossed - 119 - LRB097 05693 RPM 45756 b
and
(6) the covered person has provided all the information
and forms required to process an external review, as
specified in this Act.
(e) The following provisions apply concerning requests:
(1) Within one business day after completion of the
preliminary review, the health carrier shall notify the
Director and covered person and, if applicable, the covered
person's authorized representative in writing whether the
request is complete and eligible for external review.
(2) If the request:
(A) is not complete, then the health carrier shall
inform the Director and the covered person and, if
applicable, the covered person's authorized
representative in writing and include in the notice
what information or materials are required by this Act
to make the request complete; or
(B) is not eligible for external review, then the
health carrier shall inform the Director and the
covered person and, if applicable, the covered
person's authorized representative in writing and
include in the notice the reasons for its
ineligibility.
(3) The Department may specify the form for the health
carrier's notice of initial determination under this
subsection (e) and any supporting information to be

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included in the notice.
(4) The notice of initial determination of
ineligibility shall include a statement informing the
covered person and, if applicable, the covered person's
authorized representative that a health carrier's initial
determination that the external review request is
ineligible for review may be appealed to the Director by
filing a complaint with the Director.
(5) Notwithstanding a health carrier's initial
determination that the request is ineligible for external
review, the Director may determine that a request is
eligible for external review and require that it be
referred for external review. In making such
determination, the Director's decision shall be in
accordance with the terms of the covered person's health
benefit plan, unless such terms are inconsistent with
applicable law, and shall be subject to all applicable
provisions of this Act.
(f) Whenever a request for external review is determined
eligible for external review, the health carrier shall notify
the Director and the covered person and, if applicable, the
covered person's authorized representative.
(g) Whenever the Director receives notice that a request is
eligible for external review following the preliminary review
conducted pursuant to this Section, within one business day
after the date of receipt of the notice, the Director shall:

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(1) assign an independent review organization from the
list of approved independent review organizations compiled
and maintained by the Director pursuant to this Act and
notify the health carrier of the name of the assigned
independent review organization; and
(2) notify in writing the covered person and, if
applicable, the covered person's authorized representative
of the request's eligibility and acceptance for external
review and the name of the independent review organization.
The Director shall include in the notice provided to the
covered person and, if applicable, the covered person's
authorized representative a statement that the covered person
or the covered person's authorized representative may, within 5
business days following the date of receipt of the notice
provided pursuant to item (2) of this subsection (g), submit in
writing to the assigned independent review organization
additional information that the independent review
organization shall consider when conducting the external
review. The independent review organization is not required to,
but may, accept and consider additional information submitted
after 5 business days.
(h) The following provisions apply concerning assignments
and clinical reviews:
(1) Within one business day after the receipt of the
notice of assignment to conduct the external review
pursuant to subsection (g) of this Section, the assigned

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independent review organization shall select one or more
clinical reviewers, as it determines is appropriate,
pursuant to item (2) of this subsection (h) to conduct the
external review.
(2) The provisions of this item (2) apply concerning
the selection of reviewers:
(A) In selecting clinical reviewers pursuant to
item (1) of this subsection (h), the assigned
independent review organization shall select
physicians or other health care professionals who meet
the minimum qualifications described in Section 55 of
this Act and, through clinical experience in the past 3
years, are experts in the treatment of the covered
person's condition and knowledgeable about the
recommended or requested health care service or
treatment.
(B) Neither the covered person, the covered
person's authorized representative, if applicable, nor
the health carrier shall choose or control the choice
of the physicians or other health care professionals to
be selected to conduct the external review.
(3) In accordance with subsection (l) of this Section,
each clinical reviewer shall provide a written opinion to
the assigned independent review organization on whether
the recommended or requested health care service or
treatment should be covered.

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(4) In reaching an opinion, clinical reviewers are not
bound by any decisions or conclusions reached during the
health carrier's utilization review process or the health
carrier's internal appeal process.
(i) Within 5 business days after the date of receipt of the
notice provided pursuant to subsection (g) of this Section, the
health carrier or its designee utilization review organization
shall provide to the assigned independent review organization
the documents and any information considered in making the
adverse determination or final adverse determination; in such
cases, the following provisions shall apply:
(1) Except as provided in item (2) of this subsection
(i), failure by the health carrier or its utilization
review organization to provide the documents and
information within the specified time frame shall not delay
the conduct of the external review.
(2) If the health carrier or its utilization review
organization fails to provide the documents and
information within the specified time frame, the assigned
independent review organization may terminate the external
review and make a decision to reverse the adverse
determination or final adverse determination.
(3) Immediately upon making the decision to terminate
the external review and make a decision to reverse the
adverse determination or final adverse determination under
item (2) of this subsection (i), the independent review

HB0224 Engrossed - 124 - LRB097 05693 RPM 45756 b
organization shall notify the Director, the health
carrier, the covered person, and, if applicable, the
covered person's authorized representative of its decision
to reverse the adverse determination.
(j) Upon receipt of the information from the health carrier
or its utilization review organization, each clinical reviewer
selected pursuant to subsection (h) of this Section shall
review all of the information and documents and any other
information submitted in writing to the independent review
organization by the covered person and the covered person's
authorized representative.
(k) Upon receipt of any information submitted by the
covered person or the covered person's authorized
representative, the independent review organization shall
forward the information to the health carrier within one
business day. In such cases, the following provisions shall
apply:
(1) Upon receipt of the information, if any, the health
carrier may reconsider its adverse determination or final
adverse determination that is the subject of the external
review.
(2) Reconsideration by the health carrier of its
adverse determination or final adverse determination shall
not delay or terminate the external review.
(3) The external review may be terminated only if the
health carrier decides, upon completion of its

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reconsideration, to reverse its adverse determination or
final adverse determination and provide coverage or
payment for the health care service that is the subject of
the adverse determination or final adverse determination.
In such cases, the following provisions shall apply:
(A) Immediately upon making its decision to
reverse its adverse determination or final adverse
determination, the health carrier shall notify the
Director, the covered person and, if applicable, the
covered person's authorized representative, and the
assigned independent review organization in writing of
its decision.
(B) Upon notice from the health carrier that the
health carrier has made a decision to reverse its
adverse determination or final adverse determination,
the assigned independent review organization shall
terminate the external review.
(l) The following provisions apply concerning clinical
review opinions:
(1) Except as provided in item (3) of this subsection
(l), within 20 days after being selected in accordance with
subsection (h) of this Section to conduct the external
review, each clinical reviewer shall provide an opinion to
the assigned independent review organization on whether
the recommended or requested health care service or
treatment should be covered.

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(2) Except for an opinion provided pursuant to item (3)
of this subsection (l), each clinical reviewer's opinion
shall be in writing and include the following information:
(A) a description of the covered person's medical
condition;
(B) a description of the indicators relevant to
determining whether there is sufficient evidence to
demonstrate that the recommended or requested health
care service or treatment is more likely than not to be
beneficial to the covered person than any available
standard health care services or treatments and the
adverse risks of the recommended or requested health
care service or treatment would not be substantially
increased over those of available standard health care
services or treatments;
(C) a description and analysis of any medical or
scientific evidence considered in reaching the
opinion;
(D) a description and analysis of any
evidence-based standard; and
(E) information on whether the reviewer's
rationale for the opinion is based on clause (A) or (B)
of item (5) of subsection (m) of this Section.
(3) The provisions of this item (3) apply concerning
the timing of opinions:
(A) For an expedited external review, each

HB0224 Engrossed - 127 - LRB097 05693 RPM 45756 b
clinical reviewer shall provide an opinion orally or in
writing to the assigned independent review
organization as expeditiously as the covered person's
medical condition or circumstances requires, but in no
event more than 5 calendar days after being selected in
accordance with subsection (h) of this Section.
(B) If the opinion provided pursuant to
subdivision (A) of this item (3) was not in writing,
then within 48 hours following the date the opinion was
provided, the clinical reviewer shall provide written
confirmation of the opinion to the assigned
independent review organization and include the
information required under item (2) of this subsection
(l).
(m) In addition to the documents and information provided
by the health carrier or its utilization review organization
and the covered person and the covered person's authorized
representative, if any, each clinical reviewer selected
pursuant to subsection (h) of this Section, to the extent the
information or documents are available and the clinical
reviewer considers appropriate, shall consider the following
in reaching a decision:
(1) the covered person's pertinent medical records;
(2) the covered person's health care provider's
recommendation;
(3) consulting reports from appropriate health care

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providers and other documents submitted by the health
carrier or its designee utilization review organization,
the covered person, the covered person's authorized
representative, or the covered person's treating physician
or health care professional;
(4) the terms of coverage under the covered person's
health benefit plan with the health carrier to ensure that,
but for the health carrier's determination that the
recommended or requested health care service or treatment
that is the subject of the opinion is experimental or
investigational, the reviewer's opinion is not contrary to
the terms of coverage under the covered person's health
benefit plan with the health carrier; and
(5) whether (A) the recommended or requested health
care service or treatment has been approved by the federal
Food and Drug Administration, if applicable, for the
condition or (B) medical or scientific evidence or
evidence-based standards demonstrate that the expected
benefits of the recommended or requested health care
service or treatment is more likely than not to be
beneficial to the covered person than any available
standard health care service or treatment and the adverse
risks of the recommended or requested health care service
or treatment would not be substantially increased over
those of available standard health care services or
treatments.

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(n) The following provisions apply concerning decisions,
notices, and recommendations:
(1) The provisions of this item (1) apply concerning
decisions and notices:
(A) Except as provided in subdivision (B) of this
item (1), within 20 days after the date it receives the
opinion of each clinical reviewer, the assigned
independent review organization, in accordance with
item (2) of this subsection (n), shall make a decision
and provide written notice of the decision to the
Director, the health carrier, the covered person, and
the covered person's authorized representative, if
applicable.
(B) For an expedited external review, within 48
hours after the date it receives the opinion of each
clinical reviewer, the assigned independent review
organization, in accordance with item (2) of this
subsection (n), shall make a decision and provide
notice of the decision orally or in writing to the
Director, the health carrier, the covered person, and
the covered person's authorized representative, if
applicable. If such notice is not in writing, within 48
hours after the date of providing that notice, the
assigned independent review organization shall provide
written confirmation of the decision to the Director,
the health carrier, the covered person, and the covered

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person's authorized representative, if applicable.
(2) The provisions of this item (2) apply concerning
recommendations:
(A) If a majority of the clinical reviewers
recommend that the recommended or requested health
care service or treatment should be covered, then the
independent review organization shall make a decision
to reverse the health carrier's adverse determination
or final adverse determination.
(B) If a majority of the clinical reviewers
recommend that the recommended or requested health
care service or treatment should not be covered, the
independent review organization shall make a decision
to uphold the health carrier's adverse determination
or final adverse determination.
(C) The provisions of this subdivision (C) apply to
cases in which the clinical reviewers are evenly split:
(i) If the clinical reviewers are evenly split
as to whether the recommended or requested health
care service or treatment should be covered, then
the independent review organization shall obtain
the opinion of an additional clinical reviewer in
order for the independent review organization to
make a decision based on the opinions of a majority
of the clinical reviewers pursuant to subdivision
(A) or (B) of this item (2).

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(ii) The additional clinical reviewer selected
under clause (i) of this subdivision (C) shall use
the same information to reach an opinion as the
clinical reviewers who have already submitted
their opinions.
(iii) The selection of the additional clinical
reviewer under this subdivision (C) shall not
extend the time within which the assigned
independent review organization is required to
make a decision based on the opinions of the
clinical reviewers.
(o) The independent review organization shall include in
the notice provided pursuant to subsection (n) of this Section:
(1) a general description of the reason for the request
for external review;
(2) the written opinion of each clinical reviewer,
including the recommendation of each clinical reviewer as
to whether the recommended or requested health care service
or treatment should be covered and the rationale for the
reviewer's recommendation;
(3) the date the independent review organization
received the assignment from the Director to conduct the
external review;
(4) the time period during which the external review
was conducted;
(5) the date of its decision;

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(6) the principal reason or reasons for its decision;
and
(7) the rationale for its decision.
(p) Upon receipt of a notice of a decision reversing the
adverse determination or final adverse determination, the
health carrier shall immediately approve the coverage that was
the subject of the adverse determination or final adverse
determination.
(q) The assignment by the Director of an approved
independent review organization to conduct an external review
in accordance with this Section shall be done on a random basis
among those independent review organizations approved by the
Director pursuant to this Act.
(215 ILCS 180/55)
Sec. 55. Minimum qualifications for independent review
organizations.
(a) To be approved to conduct external reviews, an
independent review organization shall have and maintain
written policies and procedures that govern all aspects of both
the standard external review process and the expedited external
review process set forth in this Act that include, at a
minimum:
(1) a quality assurance mechanism that ensures that:
(A) external reviews are conducted within the
specified timeframes and required notices are provided

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in a timely manner;
(B) selection of qualified and impartial clinical
reviewers to conduct external reviews on behalf of the
independent review organization and suitable matching
of reviewers to specific cases and that the independent
review organization employs or contracts with an
adequate number of clinical reviewers to meet this
objective;
(C) for adverse determinations involving
experimental or investigational treatments, in
assigning clinical reviewers, the independent review
organization selects physicians or other health care
professionals who, through clinical experience in the
past 3 years, are experts in the treatment of the
covered person's condition and knowledgeable about the
recommended or requested health care service or
treatment;
(D) the health carrier, the covered person, and the
covered person's authorized representative shall not
choose or control the choice of the physicians or other
health care professionals to be selected to conduct the
external review;
(E) confidentiality of medical and treatment
records and clinical review criteria; and
(F) any person employed by or under contract with
the independent review organization adheres to the

HB0224 Engrossed - 134 - LRB097 05693 RPM 45756 b
requirements of this Act;
(2) a toll-free telephone service operating on a
24-hour-day, 7-day-a-week basis that accepts, receives,
and records information related to external reviews and
provides appropriate instructions; and
(3) an agreement to maintain and provide to the
Director the information set out in Section 70 of this Act.
(b) All clinical reviewers assigned by an independent
review organization to conduct external reviews shall be
physicians or other appropriate health care providers who meet
the following minimum qualifications:
(1) be an expert in the treatment of the covered
person's medical condition that is the subject of the
external review;
(2) be knowledgeable about the recommended health care
service or treatment through recent or current actual
clinical experience treating patients with the same or
similar medical condition of the covered person;
(3) hold a non-restricted license in a state of the
United States and, for physicians, a current certification
by a recognized American medical specialty board in the
area or areas appropriate to the subject of the external
review; and
(4) have no history of disciplinary actions or
sanctions, including loss of staff privileges or
participation restrictions, that have been taken or are

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pending by any hospital, governmental agency or unit, or
regulatory body that raise a substantial question as to the
clinical reviewer's physical, mental, or professional
competence or moral character.
(c) In addition to the requirements set forth in subsection
(a), an independent review organization may not own or control,
be a subsidiary of, or in any way be owned, or controlled by,
or exercise control with a health benefit plan, a national,
State, or local trade association of health benefit plans, or a
national, State, or local trade association of health care
providers.
(d) Conflicts of interest prohibited. In addition to the
requirements set forth in subsections (a), (b), and (c) of this
Section, to be approved pursuant to this Act to conduct an
external review of a specified case, neither the independent
review organization selected to conduct the external review nor
any clinical reviewer assigned by the independent organization
to conduct the external review may have a material
professional, familial or financial conflict of interest with
any of the following:
(1) the health carrier that is the subject of the
external review;
(2) the covered person whose treatment is the subject
of the external review or the covered person's authorized
representative;
(3) any officer, director or management employee of the

HB0224 Engrossed - 136 - LRB097 05693 RPM 45756 b
health carrier that is the subject of the external review;
(4) the health care provider, the health care
provider's medical group or independent practice
association recommending the health care service or
treatment that is the subject of the external review;
(5) the facility at which the recommended health care
service or treatment would be provided; or
(6) the developer or manufacturer of the principal
drug, device, procedure, or other therapy being
recommended for the covered person whose treatment is the
subject of the external review.
(e) An independent review organization that is accredited
by a nationally recognized private accrediting entity that has
independent review accreditation standards that the Director
has determined are equivalent to or exceed the minimum
qualifications of this Section shall be presumed to be in
compliance with this Section and shall be eligible for approval
under this Act.
(f) An independent review organization shall be unbiased.
An independent review organization shall establish and
maintain written procedures to ensure that it is unbiased in
addition to any other procedures required under this Section.
(g) Nothing in this Act precludes or shall be interpreted
to preclude a health carrier from contracting with approved
independent review organizations to conduct external reviews
assigned to it from such health carrier.

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(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/65)
Sec. 65. External review reporting requirements.
(a) Each health carrier shall maintain written records in
the aggregate, by state, and for each type of health benefit
plan offered by the health carrier on all requests for external
review that the health carrier received notice from the
Director for each calendar year and submit a report to the
Director in the format specified by the Director by March 1 of
each year.
(a-5) An independent review organization assigned pursuant
to this Act to conduct an external review shall maintain
written records in the aggregate by state and by health carrier
on all requests for external review for which it conducted an
external review during a calendar year and submit a report in
the format specified by the Director by March 1 of each year.
(a-10) The report required by subsection (a-5) shall
include in the aggregate by state, and for each health carrier:
(1) the total number of requests for external review;
(2) the number of requests for external review resolved
and, of those resolved, the number resolved upholding the
adverse determination or final adverse determination and
the number resolved reversing the adverse determination or
final adverse determination;
(3) the average length of time for resolution;

HB0224 Engrossed - 138 - LRB097 05693 RPM 45756 b
(4) a summary of the types of coverages or cases for
which an external review was sought, as provided in the
format required by the Director;
(5) the number of external reviews pursuant to Section
8G of this Act that were terminated as the result of a
reconsideration by the health carrier of its adverse
determination or final adverse determination after the
receipt of additional information from the covered person
or the covered person's authorized representative; and
(6) any other information the Director may request or
require.
(a-15) The independent review organization shall retain
the written records required pursuant to this Section for at
least 3 years.
(b) The report required under subsection (a) of this
Section shall include in the aggregate, by state, and by type
of health benefit plan:
(1) the total number of requests for external review;
(2) the total number of requests for expedited external
review;
(3) the total number of requests for external review
denied;
(4) the number of requests for external review
resolved, including:
(A) the number of requests for external review
resolved upholding the adverse determination or final

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adverse determination;
(B) the number of requests for external review
resolved reversing the adverse determination or final
adverse determination;
(C) the number of requests for expedited external
review resolved upholding the adverse determination or
final adverse determination; and
(D) the number of requests for expedited external
review resolved reversing the adverse determination or
final adverse determination;
(5) the average length of time for resolution for an
external review;
(6) the average length of time for resolution for an
expedited external review;
(7) a summary of the types of coverages or cases for
which an external review was sought, as specified below:
(A) denial of care or treatment (dissatisfaction
regarding prospective non-authorization of a request
for care or treatment recommended by a provider
excluding diagnostic procedures and referral requests;
partial approvals and care terminations are also
considered to be denials);
(B) denial of diagnostic procedure
(dissatisfaction regarding prospective
non-authorization of a request for a diagnostic
procedure recommended by a provider; partial approvals

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are also considered to be denials);
(C) denial of referral request (dissatisfaction
regarding non-authorization of a request for a
referral to another provider recommended by a PCP);
(D) claims and utilization review (dissatisfaction
regarding the concurrent or retrospective evaluation
of the coverage, medical necessity, efficiency or
appropriateness of health care services or treatment
plans; prospective "Denials of care or treatment",
"Denials of diagnostic procedures" and "Denials of
referral requests" should not be classified in this
category, but the appropriate one above);
(8) the number of external reviews that were terminated
as the result of a reconsideration by the health carrier of
its adverse determination or final adverse determination
after the receipt of additional information from the
covered person or the covered person's authorized
representative; and
(9) any other information the Director may request or
require.
(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/75)
Sec. 75. Disclosure requirements.
(a) Each health carrier shall include a description of the
external review procedures in, or attached to, the policy,

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certificate, membership booklet, and outline of coverage or
other evidence of coverage it provides to covered persons.
(b) The description required under subsection (a) of this
Section shall include a statement that informs the covered
person of the right of the covered person to file a request for
an external review of an adverse determination or final adverse
determination with the Director health carrier. The statement
shall explain that external review is available when the
adverse determination or final adverse determination involves
an issue of medical necessity, appropriateness, health care
setting, level of care, or effectiveness. The statement shall
include the toll-free telephone number and address of the
Office of Consumer Health Insurance within the Department of
Insurance.
(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/80 new)
Sec. 80. Administration and enforcement.
(a) The Director of Insurance may adopt rules necessary to
implement the Department's responsibilities under this Act.
(b) The Director is authorized to make use of any of the
powers established under the Illinois Insurance Code to enforce
the laws of this State. This includes but is not limited to,
the Director's administrative authority to investigate, issue
subpoenas, conduct depositions and hearings, issue orders,
including, without limitation, orders pursuant to Article XII

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1/2 and Section 401.1 of the Illinois Insurance Code, and
impose penalties.
(215 ILCS 134/50 rep.)
Section 90-15. The Managed Care Reform and Patient Rights
Act is amended by repealing Section 50.
ARTICLE 99.
EFFECTIVE DATE
Section 99-99. Effective date. This Act takes effect upon
becoming law.