Bill Text: IL HB0224 | 2011-2012 | 97th General Assembly | Engrossed
NOTE: There are more recent revisions of this legislation. Read Latest Draft
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
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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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | ARTICLE 5. | ||||||
5 | UTILIZATION REVIEW AND | ||||||
6 | BENEFIT DETERMINATION | ||||||
7 | Section 5-1. Short title. This Article may be cited as the | ||||||
8 | Utilization Review and Benefit Determination Law.
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9 | Section 5-5. Purpose and intent. This Law establishes | ||||||
10 | standards and criteria for the structure and operation of | ||||||
11 | utilization review and benefit determination processes | ||||||
12 | designed to facilitate ongoing assessment and management of | ||||||
13 | health care services.
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14 | Section 5-10. Definitions. For purposes of this Act:
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15 | "Adverse determination" has the same meaning given that | ||||||
16 | term in the Health Carrier Grievance Procedure Law.
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17 | "Ambulatory review" has the same meaning given that term in | ||||||
18 | the Health Carrier Grievance Procedure Law.
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19 | "Authorized representative" has the same meaning given | ||||||
20 | that term in the Health Carrier Grievance Procedure Law.
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21 | "Case management" has the same meaning given that term in |
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1 | the Health Carrier Grievance Procedure Law. | ||||||
2 | "Certification" has the same meaning given that term in the | ||||||
3 | Health Carrier Grievance Procedure Law.
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4 | "Clinical peer" has the same meaning given that term in the | ||||||
5 | Managed Care Reform and Patient Rights Law.
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6 | "Clinical review criteria" has the same meaning given that | ||||||
7 | term in the Health Carrier Grievance Procedure Law.
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8 | "Department" means the Department of Insurance.
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9 | "Director" means the Director of Insurance.
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10 | "Concurrent review" has the same meaning given that term in | ||||||
11 | the Health Carrier Grievance Procedure Law.
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12 | "Covered benefits" or "benefits" have the same meaning | ||||||
13 | given those terms in the Health Carrier Grievance Procedure | ||||||
14 | Law. | ||||||
15 | "Covered person" has the same meaning given that term in | ||||||
16 | the Health Carrier Grievance Procedure Law.
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17 | "Discharge planning" has the same meaning given that term | ||||||
18 | in the Health Carrier Grievance Procedure Law.
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19 | "Emergency medical condition" has the same meaning given | ||||||
20 | that term in the Health Carrier Grievance Procedure Law.
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21 | "Emergency services" has the same meaning given that term | ||||||
22 | in the Health Carrier Grievance Procedure Law.
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23 | "Facility" has the same meaning given that term in the | ||||||
24 | Health Carrier Grievance Procedure Law. | ||||||
25 | "Health benefit plan" has the same meaning given that term | ||||||
26 | in the Health Carrier Grievance Procedure Law.
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1 | "Health care professional" has the same meaning given that | ||||||
2 | term in the Health Carrier Grievance Procedure Law.
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3 | "Health care provider" or "provider" has the same meaning | ||||||
4 | given that term in the Health Carrier Grievance Procedure Law.
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5 | "Health care services" has the same meaning given that term | ||||||
6 | in the Health Carrier Grievance Procedure Law.
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7 | "Health carrier" has the same meaning given that term in | ||||||
8 | the Health Carrier Grievance Procedure Law.
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9 | "Managed care plan" has the same meaning given that term in | ||||||
10 | the Health Carrier Grievance Procedure Law.
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11 | "Network" has the same meaning given that term in the | ||||||
12 | Health Carrier Grievance Procedure Law.
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13 | "Participating provider" means a provider who, under a | ||||||
14 | contract with the health carrier or with its contractor or | ||||||
15 | subcontractor, has agreed to provide health care services to | ||||||
16 | covered persons with an expectation of receiving payment, other | ||||||
17 | than coinsurance, copayments, or deductibles, directly or | ||||||
18 | indirectly from the health carrier.
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19 | "Person" has the same meaning given that term in the Health | ||||||
20 | Carrier Grievance Procedure Law. | ||||||
21 | "Prospective review" has the same meaning given that term | ||||||
22 | in the Health Carrier Grievance Procedure Law.
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23 | "Rescission" has the same meaning given that term in the | ||||||
24 | Health Carrier Grievance Procedure Law.
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25 | "Retrospective review" has the same meaning given that term | ||||||
26 | in the Health Carrier Grievance Procedure Law.
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1 | "Second opinion" has the same meaning given that term in | ||||||
2 | the Health Carrier Grievance Procedure Law.
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3 | "Stabilization" has the same meaning given that term in the | ||||||
4 | Managed Care Reform and Patient Rights Act.
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5 | "Urgent care request" has the same meaning given that term | ||||||
6 | in the Health Carrier Grievance Procedure Law.
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7 | "Utilization review" has the same meaning given that term | ||||||
8 | in the Managed Care Reform and Patient Rights Act.
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9 | "Utilization review organization" means a utilization | ||||||
10 | review program as defined in the Managed Care Reform and | ||||||
11 | Patient Rights Act.
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12 | Section 5-15. Applicability and scope. This Law shall apply | ||||||
13 | to a health carrier offering a health benefit plan that | ||||||
14 | provides or performs utilization review services. The | ||||||
15 | requirements of this Law also shall apply to any designee of | ||||||
16 | the health carrier or utilization review organization that | ||||||
17 | performs utilization review functions on the carrier's behalf. | ||||||
18 | This Law also shall apply to a health carrier or its designee | ||||||
19 | utilization review organization that provides or performs | ||||||
20 | concurrent review, prospective review, or retrospective review | ||||||
21 | benefit determinations.
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22 | Section 5-20. Corporate oversight of utilization review | ||||||
23 | program. A health carrier shall be responsible for monitoring | ||||||
24 | all utilization review activities carried out by, or on behalf |
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1 | of, the health carrier and for ensuring that all requirements | ||||||
2 | of this Law and applicable regulations are met. The health | ||||||
3 | carrier also shall ensure that appropriate personnel have | ||||||
4 | operational responsibility for the conduct of the health | ||||||
5 | carrier's utilization review program.
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6 | Section 5-25. Contracting. Whenever a health carrier | ||||||
7 | contracts to have a utilization review organization or other | ||||||
8 | entity perform the utilization review functions required by | ||||||
9 | this Law or applicable regulations, the Director shall hold the | ||||||
10 | health carrier responsible for monitoring the activities of the | ||||||
11 | utilization review organization or entity with which the health | ||||||
12 | carrier contracts and for ensuring that the requirements of | ||||||
13 | this Law and applicable regulations are met.
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14 | Section 5-30. Scope and content of utilization review | ||||||
15 | program.
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16 | (a) A health carrier that requires a request for benefits | ||||||
17 | under the covered person's health benefit plan to be subjected | ||||||
18 | to utilization review shall implement a written utilization | ||||||
19 | review program that describes all review activities and | ||||||
20 | procedures, both delegated and non-delegated, for the | ||||||
21 | following:
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22 | (1) the filing of benefit requests;
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23 | (2) the notification of utilization review and benefit | ||||||
24 | determinations; and
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1 | (3) the review of adverse determinations in accordance | ||||||
2 | with the Health Carrier Grievance Procedure Law.
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3 | (b) The program document shall describe the following:
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4 | (1) procedures to evaluate the medical necessity, | ||||||
5 | appropriateness, efficacy, or efficiency of health care | ||||||
6 | services;
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7 | (2) data sources and clinical review criteria used in | ||||||
8 | decision-making;
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9 | (3) mechanisms to ensure consistent application of | ||||||
10 | clinical review criteria and compatible decisions;
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11 | (4) data collection processes and analytical methods | ||||||
12 | used in assessing utilization of health care services;
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13 | (5) provisions for assuring confidentiality of | ||||||
14 | clinical and proprietary information;
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15 | (6) the organizational structure, including, but not | ||||||
16 | limited to, utilization review committee, quality | ||||||
17 | assurance committee, or other committee that periodically | ||||||
18 | assesses utilization review activities and reports to the | ||||||
19 | health carrier's governing body; and
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20 | (7) the staff position functionally responsible for | ||||||
21 | day-to-day program management.
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22 | (c) A health carrier shall file an annual summary report of | ||||||
23 | its utilization review program activities with the Director in | ||||||
24 | the format specified by the Director.
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25 | (d) A health carrier shall maintain records for a minimum | ||||||
26 | of 6 years of all benefit requests and claims and notices |
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1 | associated with utilization review and benefit determinations | ||||||
2 | made in accordance with Sections 5-40 and 5-45 of this Law. The | ||||||
3 | health carrier shall make the records available for examination | ||||||
4 | by covered persons and the Department upon request.
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5 | Section 5-35. Operational requirements.
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6 | (a) A utilization review program shall use documented | ||||||
7 | clinical review criteria that are based on sound clinical | ||||||
8 | evidence and are evaluated periodically to assure ongoing | ||||||
9 | efficacy. A health carrier may develop its own clinical review | ||||||
10 | criteria or it may purchase or license clinical review criteria | ||||||
11 | from qualified vendors. A health carrier shall make available | ||||||
12 | its clinical review criteria upon request to the Department.
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13 | (b) Qualified health care professionals shall administer | ||||||
14 | the utilization review program and oversee utilization review | ||||||
15 | decisions. A clinical peer shall evaluate the clinical | ||||||
16 | appropriateness of adverse determinations.
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17 | (c) A health carrier shall issue utilization review and | ||||||
18 | benefit determinations in a timely manner pursuant to the | ||||||
19 | requirements of Sections 5-40 and 5-45 of this Law.
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20 | (d) The following provisions shall apply: | ||||||
21 | (1) Whenever a health carrier fails to strictly adhere | ||||||
22 | to the requirements of Sections 5-40 or 5-45 of this Law | ||||||
23 | with respect to making utilization review and benefit | ||||||
24 | determinations of a benefit request or claim, the covered | ||||||
25 | person shall be deemed to have exhausted the provisions of |
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1 | this Law and may take action under paragraph (2) of this | ||||||
2 | subsection (d) regardless of whether the health carrier | ||||||
3 | asserts that it substantially complied with the | ||||||
4 | requirements of Sections 5-40 or 5-45 of this Law, as | ||||||
5 | applicable, or that any error it committed was de minimus.
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6 | (2) A covered person may file a request for external | ||||||
7 | review in accordance with the procedures outlined in the | ||||||
8 | Health Carrier External Review Act. In addition, a covered | ||||||
9 | person is entitled to pursue any available remedies under | ||||||
10 | State or federal law on the basis that the health carrier | ||||||
11 | failed to provide a reasonable internal claims and appeals | ||||||
12 | process that would yield a decision on the merits of the | ||||||
13 | claim.
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14 | (e) A health carrier shall have a process to ensure that | ||||||
15 | utilization reviewers apply clinical review criteria in | ||||||
16 | conducting utilization review consistently.
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17 | (f) A health carrier shall routinely assess the | ||||||
18 | effectiveness and efficiency of its utilization review | ||||||
19 | program.
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20 | (g) A health carrier's data systems shall be sufficient to | ||||||
21 | support utilization review program activities and to generate | ||||||
22 | management reports to enable the health carrier to monitor and | ||||||
23 | manage health care services effectively.
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24 | (h) If a health carrier delegates any utilization review | ||||||
25 | activities to a utilization review organization, then the | ||||||
26 | health carrier shall maintain adequate oversight, which shall |
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1 | include:
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2 | (1) a written description of the utilization review | ||||||
3 | organization's activities and responsibilities, including | ||||||
4 | reporting requirements;
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5 | (2) evidence of formal approval of the utilization | ||||||
6 | review organization program by the health carrier; and
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7 | (3) a process by which the health carrier evaluates the | ||||||
8 | performance of the utilization review organization.
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9 | (i) The health carrier shall coordinate the utilization | ||||||
10 | review program with other medical management activity | ||||||
11 | conducted by the carrier, such as quality assurance, | ||||||
12 | credentialing, provider contracting, data reporting, grievance | ||||||
13 | procedures, processes for assessing member satisfaction, and | ||||||
14 | risk management.
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15 | (j) A health carrier shall provide covered persons and | ||||||
16 | participating providers with access to its review staff by a | ||||||
17 | toll-free number or collect-call telephone line.
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18 | (k) When conducting utilization review, the health carrier | ||||||
19 | shall collect only the information necessary, including | ||||||
20 | pertinent clinical information, to make the utilization review | ||||||
21 | or benefit determination.
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22 | (l) In conducting utilization review, the health carrier | ||||||
23 | shall ensure that the review is conducted in a manner to ensure | ||||||
24 | the independence and impartiality of the individuals involved | ||||||
25 | in making the utilization review or benefit determination. In | ||||||
26 | ensuring the independence and impartially of individuals |
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1 | involved in making the utilization review or benefit | ||||||
2 | determination, the health carrier shall not make decisions | ||||||
3 | regarding hiring, compensation, termination, promotion, or | ||||||
4 | other similar matters based upon the likelihood that the | ||||||
5 | individual will support the denial of benefits.
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6 | Section 5-40. Procedures for standard utilization review | ||||||
7 | and benefit determinations.
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8 | (a) A health carrier shall maintain written procedures | ||||||
9 | pursuant to this Section for making standard utilization review | ||||||
10 | and benefit determinations on requests submitted to the health | ||||||
11 | carrier by covered persons or their authorized representatives | ||||||
12 | for benefits and for notifying covered persons and their | ||||||
13 | authorized representatives of its determinations with respect | ||||||
14 | to these requests within the specified time frames required | ||||||
15 | under this Section.
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16 | (b) Subject to subsection (d) of this Section, for | ||||||
17 | prospective review determinations, a health carrier shall make | ||||||
18 | the determination and notify the covered person or, if | ||||||
19 | applicable, the covered person's authorized representative of | ||||||
20 | the determination, whether the carrier certifies the provision | ||||||
21 | of the benefit or not, within a reasonable period of time | ||||||
22 | appropriate to the covered person's medical condition, but in | ||||||
23 | no event later than 15 days after the date the health carrier | ||||||
24 | receives the request.
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25 | (c) Whenever the determination is an adverse |
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1 | determination, the health carrier shall make the notification | ||||||
2 | of the adverse determination in accordance with subsection (q) | ||||||
3 | of this Section.
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4 | (d) The time period for making a determination and | ||||||
5 | notifying the covered person or, if applicable, the covered | ||||||
6 | person's authorized representative of the determination | ||||||
7 | pursuant to subsections (b) and (c) of this Section may be | ||||||
8 | extended one time by the health carrier for up to 15 days, | ||||||
9 | provided the health carrier:
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10 | (1) determines that an extension is necessary due to | ||||||
11 | matters beyond the health carrier's control; and
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12 | (2) notifies the covered person or, if applicable, the | ||||||
13 | covered person's authorized representative, prior to the | ||||||
14 | expiration of the initial 15-day time period, of the | ||||||
15 | circumstances requiring the extension of time and the date | ||||||
16 | by which the health carrier expects to make a | ||||||
17 | determination.
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18 | (e) If the extension under subsection (d) of this Section | ||||||
19 | is necessary due to the failure of the covered person or the | ||||||
20 | covered person's authorized representative to submit | ||||||
21 | information necessary to reach a determination on the request, | ||||||
22 | then the notice of extension shall:
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23 | (1) specifically describe the required information | ||||||
24 | necessary to complete the request; and
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25 | (2) give the covered person or, if applicable, the | ||||||
26 | covered person's authorized representative at least 45 |
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1 | days from the date of receipt of the notice to provide the | ||||||
2 | specified information.
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3 | (f) Whenever the health carrier receives a prospective | ||||||
4 | review request from a covered person or the covered person's | ||||||
5 | authorized representative that fails to meet the health | ||||||
6 | carrier's filing procedures, the health carrier shall notify | ||||||
7 | the covered person or, if applicable, the covered person's | ||||||
8 | authorized representative of this failure and provide in the | ||||||
9 | notice information on the proper procedures to be followed for | ||||||
10 | filing a request.
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11 | (g) The notice required under subsection (f) of this | ||||||
12 | Section shall be provided, as soon as possible, but in no event | ||||||
13 | later than 5 days following the date of the failure. The health | ||||||
14 | carrier may provide the notice orally or, if requested by the | ||||||
15 | covered person or the covered person's authorized | ||||||
16 | representative, in writing.
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17 | (h) The provisions of subsections (f) and (g) shall apply | ||||||
18 | only in the case of a failure that:
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19 | (1) is a communication by a covered person or the | ||||||
20 | covered person's authorized representative that is | ||||||
21 | received by a person or organizational unit of the health | ||||||
22 | carrier responsible for handling benefit matters; and
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23 | (2) is a communication that refers to a specific | ||||||
24 | covered person, a specific medical condition or symptom, | ||||||
25 | and a specific health care service, treatment, or provider | ||||||
26 | for which certification is being requested.
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1 | (i) For concurrent review determinations, if a health | ||||||
2 | carrier has certified an ongoing course of treatment to be | ||||||
3 | provided over a period of time or number of treatments, then | ||||||
4 | the following provisions shall apply:
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5 | (1) any reduction or termination by the health carrier | ||||||
6 | during the course of treatment before the end of the period | ||||||
7 | or number treatments, other than by a health benefit plan | ||||||
8 | amendment or termination of the health benefit plan, shall | ||||||
9 | constitute an adverse determination; | ||||||
10 | (2) the health carrier shall notify the covered person | ||||||
11 | of the adverse determination in accordance with subsection | ||||||
12 | (q) of this Section at a time sufficiently in advance of | ||||||
13 | the reduction or termination to allow the covered person | ||||||
14 | or, if applicable, the covered person's authorized | ||||||
15 | representative to file a grievance to request a review of | ||||||
16 | the adverse determination pursuant to the Health Carrier | ||||||
17 | Grievance Procedure Law and obtain a determination with | ||||||
18 | respect to that review of the adverse determination before | ||||||
19 | the benefit is reduced or terminated; and | ||||||
20 | (3) the health care service or treatment that is the | ||||||
21 | subject of the adverse determination shall be continued | ||||||
22 | without liability to the covered person with respect to the | ||||||
23 | internal review request made pursuant to Health Carrier | ||||||
24 | Grievance Procedure Law.
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25 | (j) For retrospective review determinations, a health | ||||||
26 | carrier shall make the determination within a reasonable period |
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1 | of time, but in no event later than 30 days after the date of | ||||||
2 | receiving the benefit request.
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3 | (k) If the determination is an adverse determination, then | ||||||
4 | the health carrier shall provide notice of the adverse | ||||||
5 | determination to the covered person or, if applicable, the | ||||||
6 | covered person's authorized representative in accordance with | ||||||
7 | subsection (q) of this Section.
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8 | (l) The time period for making a determination and | ||||||
9 | notifying the covered person or, if applicable, the covered | ||||||
10 | person's authorized representative of the determination | ||||||
11 | pursuant to subsections (j) and (k) of this Section may be | ||||||
12 | extended one time by the health carrier for up to 15 days, | ||||||
13 | provided the health carrier:
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14 | (1) determines that an extension is necessary due to | ||||||
15 | matters beyond the health carrier's control; and
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16 | (2) notifies the covered person or, if applicable, the | ||||||
17 | covered person's authorized representative, prior to the | ||||||
18 | expiration of the initial 30-day time period, of the | ||||||
19 | circumstances requiring the extension of time and the date | ||||||
20 | by which the health carrier expects to make a | ||||||
21 | determination.
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22 | (m) If the extension under subsection (l) of this Section | ||||||
23 | is necessary due to the failure of the covered person or, if | ||||||
24 | applicable, the covered person's authorized representative to | ||||||
25 | submit information necessary to reach a determination on the | ||||||
26 | request, the notice of extension shall:
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1 | (1) specifically describe the required information | ||||||
2 | necessary to complete the request; and
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3 | (2) give the covered person or, if applicable, the | ||||||
4 | covered person's authorized representative at least 45 | ||||||
5 | days after the date of receipt of the notice to provide the | ||||||
6 | specified information.
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7 | (n) For purposes of calculating the time periods within | ||||||
8 | which a determination is required to be made under this | ||||||
9 | Section, the time period within which the determination is | ||||||
10 | required to be made shall begin on the date the request is | ||||||
11 | received by the health carrier in accordance with the health | ||||||
12 | carrier's procedures established pursuant to Section 5-30 of | ||||||
13 | this Law for filing a request without regard to whether all of | ||||||
14 | the information necessary to make the determination | ||||||
15 | accompanies the filing.
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16 | (o) If the time period for making the determination under | ||||||
17 | this Section is extended due to the covered person's or, if | ||||||
18 | applicable, the covered person's authorized representative's | ||||||
19 | failure to submit the information necessary to make the | ||||||
20 | determination, the time period for making the determination | ||||||
21 | shall be tolled from the date on which the health carrier sends | ||||||
22 | the notification of the extension to the covered person or, if | ||||||
23 | applicable, the covered person's authorized representative | ||||||
24 | until the earlier of:
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25 | (1) the date on which the covered person or, if | ||||||
26 | applicable, the covered person's authorized representative |
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1 | responds to the request for additional information; or
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2 | (2) the date on which the specified information was to | ||||||
3 | have been submitted.
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4 | (p) If the covered person or the covered person's | ||||||
5 | authorized representative fails to submit the information | ||||||
6 | before the end of the period of the extension as specified in | ||||||
7 | this Section, then the health carrier may deny the | ||||||
8 | certification of the requested benefit. | ||||||
9 | (q) Notice requirements are as follows:
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10 | (1) A notification of an adverse determination under | ||||||
11 | this Section shall, in a manner calculated to be understood | ||||||
12 | by the covered person, set forth:
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13 | (A) information sufficient to identify the benefit | ||||||
14 | request or claim involved, including the date of | ||||||
15 | service, if applicable, the health care provider, the | ||||||
16 | claim amount, if applicable, the diagnosis code and its | ||||||
17 | corresponding meaning, and the treatment code and its | ||||||
18 | corresponding meaning;
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19 | (B) the specific reasons or reasons for the adverse | ||||||
20 | determination, including the denial code and its | ||||||
21 | corresponding meaning, as well as a description of the | ||||||
22 | health carrier's standard, if any, that was used in | ||||||
23 | denying the benefit request or claim;
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24 | (C) reference to the specific plan provisions on | ||||||
25 | which the determination is based;
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26 | (D) a description of any additional material or |
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1 | information necessary for the covered person to | ||||||
2 | perfect the benefit request, including an explanation | ||||||
3 | of why the material or information is necessary to | ||||||
4 | perfect the request;
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5 | (E) a description of the health carrier's | ||||||
6 | grievance procedures established pursuant to the | ||||||
7 | Health Carrier Grievance Procedure Law, including any | ||||||
8 | time limits applicable to those procedures;
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9 | (F) if the health carrier relied upon an internal | ||||||
10 | rule, guideline, protocol, or other similar criterion | ||||||
11 | to make the adverse determination, either the specific | ||||||
12 | rule, guideline, protocol, or other similar criterion | ||||||
13 | or a statement that a specific rule, guideline, | ||||||
14 | protocol, or other similar criterion was relied upon to | ||||||
15 | make the adverse determination and that a copy of the | ||||||
16 | rule, guideline, protocol, or other similar criterion | ||||||
17 | will be provided free of charge to the covered person | ||||||
18 | upon request;
| ||||||
19 | (G) if the adverse determination is based on a | ||||||
20 | medical necessity or experimental or investigational | ||||||
21 | treatment or similar exclusion or limit, either an | ||||||
22 | explanation of the scientific or clinical judgment for | ||||||
23 | making the determination, applying the terms of the | ||||||
24 | health benefit plan to the covered person's medical | ||||||
25 | circumstances or a statement that an explanation will | ||||||
26 | be provided to the covered person free of charge upon |
| |||||||
| |||||||
1 | request;
| ||||||
2 | (H) a copy of the rule, guideline, protocol, or | ||||||
3 | other similar criterion relied upon in making the | ||||||
4 | adverse determination, as provided in subparagraph (F) | ||||||
5 | of this paragraph (1); or
| ||||||
6 | (I) the written statement of the scientific or | ||||||
7 | clinical rationale for the adverse determination, as | ||||||
8 | provided in subparagraph (G) of this paragraph (1); and
| ||||||
9 | (J) a statement explaining the availability of and | ||||||
10 | the right of the covered person, as appropriate, to | ||||||
11 | contact the Department or the Office of Consumer Health | ||||||
12 | Insurance at any time for assistance or, upon | ||||||
13 | completion of the health carrier's grievance procedure | ||||||
14 | process as provided under the Health Carrier Grievance | ||||||
15 | Procedure Law, to file a civil suit in a court of | ||||||
16 | competent jurisdiction; the statement shall include | ||||||
17 | contact information for the Department and the Office | ||||||
18 | of Consumer Health Insurance.
| ||||||
19 | (2) A health carrier shall provide the notice required | ||||||
20 | under this Section in a culturally and linguistically | ||||||
21 | appropriate manner if required in accordance with federal | ||||||
22 | regulations. If a health carrier is required to provide the | ||||||
23 | notice required under this Section in a culturally and | ||||||
24 | linguistically appropriate manner in accordance with | ||||||
25 | federal regulations, then the health carrier shall:
| ||||||
26 | (A) include a statement in the English version of |
| |||||||
| |||||||
1 | the notice, prominently displayed in the non-English | ||||||
2 | language, offering the provision of the notice in the | ||||||
3 | non-English language;
| ||||||
4 | (B) once a utilization review or benefit | ||||||
5 | determination request has been made by a covered | ||||||
6 | person, provide all subsequent notices to the covered | ||||||
7 | person in the non-English language; and
| ||||||
8 | (C) to the extent the health carrier maintains a | ||||||
9 | consumer assistance process, such as a telephone | ||||||
10 | hotline that answers questions or provides assistance | ||||||
11 | with filing claims and appeals, provide this | ||||||
12 | assistance in the non-English language.
| ||||||
13 | (3) If the adverse determination is a rescission, then | ||||||
14 | the health carrier shall, in addition to any applicable | ||||||
15 | disclosures required under this subsection (q), provide:
| ||||||
16 | (A) clear identification of the alleged fraudulent | ||||||
17 | act, practice, or omission or the intentional | ||||||
18 | misrepresentation of material fact;
| ||||||
19 | (B) an explanation as to why the act, practice, or | ||||||
20 | omission was fraudulent or was an intentional | ||||||
21 | misrepresentation of a material fact;
| ||||||
22 | (C) notice that the covered person or the covered | ||||||
23 | person's authorized representative, prior to the | ||||||
24 | effective date of the proposed rescission, may | ||||||
25 | immediately file a grievance to request a review of the | ||||||
26 | adverse determination to rescind coverage pursuant to |
| |||||||
| |||||||
1 | the Health Carrier Grievance Procedure Law;
| ||||||
2 | (D) a description of the health carrier's | ||||||
3 | grievance procedures established pursuant to the | ||||||
4 | Health Carrier Grievance Procedure Law, including any | ||||||
5 | time limits applicable to those procedures; and
| ||||||
6 | (E) the effective date of the proposed rescission | ||||||
7 | and the date back to which the coverage will be | ||||||
8 | retroactively rescinded.
| ||||||
9 | (4) A health carrier must provide the notice required | ||||||
10 | under this Section in writing.
| ||||||
11 | Section 5-45. Procedures for expedited utilization review | ||||||
12 | and benefit determinations.
| ||||||
13 | (a) A health carrier shall establish written procedures in | ||||||
14 | accordance with this Section for receiving benefit requests | ||||||
15 | from covered persons or their authorized representatives and | ||||||
16 | for making and notifying covered persons or their authorized | ||||||
17 | representatives of expedited utilization review and benefit | ||||||
18 | determinations with respect to urgent care requests and | ||||||
19 | concurrent review urgent care requests.
| ||||||
20 | (b) As part of the procedures required under subsection (a) | ||||||
21 | of this Section, a health carrier shall provide that, in the | ||||||
22 | case of a failure by a covered person or the covered person's | ||||||
23 | authorized representative to follow the health carrier's | ||||||
24 | procedures for filing an urgent care request, the covered | ||||||
25 | person or the covered person's authorized representative shall |
| |||||||
| |||||||
1 | be notified of the failure and the proper procedures to be | ||||||
2 | followed for filing the request.
| ||||||
3 | (c) The notice required under subsection (b) of this | ||||||
4 | Section:
| ||||||
5 | (1) shall be provided to the covered person or the | ||||||
6 | covered person's authorized representative, as | ||||||
7 | appropriate, as soon as possible, but not later than 24 | ||||||
8 | hours after receipt of the request; and
| ||||||
9 | (2) may be oral, unless the covered person or the | ||||||
10 | covered person's authorized representative requests the | ||||||
11 | notice in writing.
| ||||||
12 | (d) The provisions of subsections (b) and (c) of this | ||||||
13 | Section apply only in the case of a failure that:
| ||||||
14 | (1) is a communication by a covered person or, if | ||||||
15 | applicable, the covered person's authorized representative | ||||||
16 | that is received by a person or organizational unit of the | ||||||
17 | health carrier responsible for handling benefit matters; | ||||||
18 | and
| ||||||
19 | (2) is a communication that refers to a specific | ||||||
20 | covered person, a specific medical condition or symptom, | ||||||
21 | and a specific health care service, treatment or provider | ||||||
22 | for which approval is being requested.
| ||||||
23 | (e) For an urgent care request, unless the covered person | ||||||
24 | or the covered person's authorized representative has failed to | ||||||
25 | provide sufficient information for the health carrier to | ||||||
26 | determine whether, or to what extent, the benefits requested |
| |||||||
| |||||||
1 | are covered benefits or payable under the health carrier's | ||||||
2 | health benefit plan, the health carrier shall notify the | ||||||
3 | covered person or, if applicable, the covered person's | ||||||
4 | authorized representative of the health carrier's | ||||||
5 | determination with respect to the request, whether or not the | ||||||
6 | determination is an adverse determination, as soon as possible, | ||||||
7 | taking into account the medical condition of the covered | ||||||
8 | person, but in no event later than 24 hours after the receipt | ||||||
9 | of the request by the health carrier.
| ||||||
10 | (f) If the health carrier's determination is an adverse | ||||||
11 | determination, then the health carrier shall provide notice of | ||||||
12 | the adverse determination in accordance with subsection (o) of | ||||||
13 | this Section.
| ||||||
14 | (g) If the covered person or, if applicable, the covered | ||||||
15 | person's authorized representative has failed to provide | ||||||
16 | sufficient information for the health carrier to make a | ||||||
17 | determination, then the health carrier shall notify the covered | ||||||
18 | person or, if applicable, the covered person's authorized | ||||||
19 | representative either orally or, if requested by the covered | ||||||
20 | person or the covered person's authorized representative, in | ||||||
21 | writing of this failure and state what specific information is | ||||||
22 | needed as soon as possible, but in no event later than 24 hours | ||||||
23 | after receipt of the request.
| ||||||
24 | (h) The health carrier shall provide the covered person or, | ||||||
25 | if applicable, the covered person's authorized representative | ||||||
26 | a reasonable period of time to submit the necessary |
| |||||||
| |||||||
1 | information, taking into account the circumstances, but in no | ||||||
2 | event less than 48 hours after notifying the covered person or | ||||||
3 | the covered person's authorized representative of the failure | ||||||
4 | to submit sufficient information, as provided in subsection (g) | ||||||
5 | of this Section.
| ||||||
6 | (i) The health carrier shall notify the covered person or, | ||||||
7 | if applicable, the covered person's authorized representative | ||||||
8 | of its determination with respect to the urgent care request as | ||||||
9 | soon as possible, but in no event more than 48 hours after the | ||||||
10 | earlier of:
| ||||||
11 | (1) the health carrier's receipt of the requested | ||||||
12 | specified information; or
| ||||||
13 | (2) the end of the period provided for the covered | ||||||
14 | person or, if applicable, the covered person's authorized | ||||||
15 | representative to submit the requested specified | ||||||
16 | information.
| ||||||
17 | (j) If the covered person or the covered person's | ||||||
18 | authorized representative fails to submit the information | ||||||
19 | before the end of the period of the extension, as specified in | ||||||
20 | subsection (h) of this Section, then the health carrier may | ||||||
21 | deny the certification of the requested benefit.
| ||||||
22 | (k) If the health carrier's determination is an adverse | ||||||
23 | determination, then the health carrier shall provide notice of | ||||||
24 | the adverse determination in accordance with subsection (o) of | ||||||
25 | this Section.
| ||||||
26 | (l) For concurrent review urgent care requests involving a |
| |||||||
| |||||||
1 | request by the covered person or the covered person's | ||||||
2 | authorized representative to extend the course of treatment | ||||||
3 | beyond the initial period of time or the number of treatments, | ||||||
4 | if the request is made at least 24 hours prior to the | ||||||
5 | expiration of the prescribed period of time or number of | ||||||
6 | treatments, then the health carrier shall make a determination | ||||||
7 | with respect to the request and notify the covered person or, | ||||||
8 | if applicable, the covered person's authorized representative | ||||||
9 | of the determination, whether it is an adverse determination or | ||||||
10 | not, as soon as possible, taking into account the covered | ||||||
11 | person's medical condition, but in no event more than 24 hours | ||||||
12 | after the health carrier's receipt of the request.
| ||||||
13 | (m) If the health carrier's determination is an adverse | ||||||
14 | determination, then the health carrier shall provide notice of | ||||||
15 | the adverse determination in accordance with subsection (o) of | ||||||
16 | this Section.
| ||||||
17 | (n) For purposes of calculating the time periods within | ||||||
18 | which a determination is required to be made under this | ||||||
19 | Section, the time period within which the determination is | ||||||
20 | required to be made shall begin on the date the request is | ||||||
21 | filed with the health carrier in accordance with the health | ||||||
22 | carrier's procedures established pursuant to Section 5-30 of | ||||||
23 | this Law for filing a request without regard to whether all of | ||||||
24 | the information necessary to make the determination | ||||||
25 | accompanies the filing.
| ||||||
26 | (o) Notice requirements are as follows:
|
| |||||||
| |||||||
1 | (1) A notification of an adverse determination under | ||||||
2 | this Section shall, in a manner calculated to be understood | ||||||
3 | by the covered person, set forth:
| ||||||
4 | (A) information sufficient to identify the benefit | ||||||
5 | request or claim involved, including the date of | ||||||
6 | service, if applicable, the health care provider, the | ||||||
7 | claim amount, if applicable, the diagnosis code and its | ||||||
8 | corresponding meaning and the treatment code and its | ||||||
9 | corresponding meaning;
| ||||||
10 | (B) the specific reasons or reasons for the adverse | ||||||
11 | determination, including the denial code and its | ||||||
12 | corresponding meaning, as well as a description of the | ||||||
13 | health carrier's standard, if any, that was used in | ||||||
14 | denying the benefit request or claim;
| ||||||
15 | (C) reference to the specific plan provisions on | ||||||
16 | which the determination is based;
| ||||||
17 | (D) a description of any additional material or | ||||||
18 | information necessary for the covered person to | ||||||
19 | complete the request, including an explanation of why | ||||||
20 | the material or information is necessary to complete | ||||||
21 | the request;
| ||||||
22 | (E) a description of the health carrier's internal | ||||||
23 | review procedures established pursuant to the Health | ||||||
24 | Carrier Grievance Procedure Law, including any time | ||||||
25 | limits applicable to those procedures;
| ||||||
26 | (F) a description of the health carrier's |
| |||||||
| |||||||
1 | expedited review procedures established pursuant to | ||||||
2 | Section 10-40 of the Health Carrier Grievance | ||||||
3 | Procedure Law;
| ||||||
4 | (G) if the health carrier relied upon an internal | ||||||
5 | rule, guideline, protocol, or other similar criterion | ||||||
6 | to make the adverse determination, either the specific | ||||||
7 | rule, guideline, protocol, or other similar criterion | ||||||
8 | or a statement that a specific rule, guideline, | ||||||
9 | protocol, or other similar criterion was relied upon to | ||||||
10 | make the adverse determination and that a copy of the | ||||||
11 | rule, guideline, protocol, or other similar criterion | ||||||
12 | will be provided free of charge to the covered person | ||||||
13 | upon request;
| ||||||
14 | (H) if the adverse determination is based on a | ||||||
15 | medical necessity or experimental or investigational | ||||||
16 | treatment or similar exclusion or limit, either an | ||||||
17 | explanation of the scientific or clinical judgment for | ||||||
18 | making the determination, applying the terms of the | ||||||
19 | health benefit plan to the covered person's medical | ||||||
20 | circumstances or a statement that an explanation will | ||||||
21 | be provided to the covered person free of charge upon | ||||||
22 | request;
| ||||||
23 | (I) if applicable, instructions for requesting:
| ||||||
24 | (i) a copy of the rule, guideline, protocol, or | ||||||
25 | other similar criterion relied upon in making the | ||||||
26 | adverse determination in accordance with |
| |||||||
| |||||||
1 | subparagraph (G) of this paragraph (1); or
| ||||||
2 | (ii) the written statement of the scientific | ||||||
3 | or clinical rationale for the adverse | ||||||
4 | determination in accordance with subparagraph (H) | ||||||
5 | of this paragraph (1); and | ||||||
6 | (J) a statement explaining the availability of and | ||||||
7 | the right of the covered person, as appropriate, to | ||||||
8 | contact the Department or the Office of Consumer Health | ||||||
9 | Insurance at any time for assistance or, upon | ||||||
10 | completion of the health carrier's grievance procedure | ||||||
11 | process as provided under the Health Carrier Grievance | ||||||
12 | Procedure Law, to file a civil suit in a court of | ||||||
13 | competent jurisdiction; the statement shall include | ||||||
14 | contact information for the Department and the Office | ||||||
15 | of Consumer Health Insurance.
| ||||||
16 | (2) A health carrier shall provide the notice required | ||||||
17 | under this Section in a culturally and linguistically | ||||||
18 | appropriate manner if required in accordance with federal | ||||||
19 | regulations. If a health carrier is required to provide the | ||||||
20 | notice required under this Section in a culturally and | ||||||
21 | linguistically appropriate manner in accordance with | ||||||
22 | federal regulations, the health carrier shall do the | ||||||
23 | following:
| ||||||
24 | (A) include a statement in the English version of | ||||||
25 | the notice, prominently displayed in the non-English | ||||||
26 | language, offering the provision of the notice in the |
| |||||||
| |||||||
1 | non-English language;
| ||||||
2 | (B) once a utilization review or benefit | ||||||
3 | determination request has been made by a covered | ||||||
4 | person, provide all subsequent notices to the covered | ||||||
5 | person in the non-English language; and
| ||||||
6 | (C) to the extent the health carrier maintains a | ||||||
7 | consumer assistance process, such as a telephone | ||||||
8 | hotline that answers questions or provides assistance | ||||||
9 | with filing claims and appeals, the health carrier | ||||||
10 | shall provide this assistance in the non-English | ||||||
11 | language.
| ||||||
12 | (3) If the adverse determination is a rescission, then | ||||||
13 | the health carrier shall provide the following, in addition | ||||||
14 | to any applicable disclosures required under this | ||||||
15 | subsection (o):
| ||||||
16 | (A) clear identification of the alleged fraudulent | ||||||
17 | act, practice or omission or the intentional | ||||||
18 | misrepresentation of material fact;
| ||||||
19 | (B) an explanation as to why the act, practice or | ||||||
20 | omission was fraudulent or was an intentional | ||||||
21 | misrepresentation of a material fact;
| ||||||
22 | (C) the date the health carrier made the decision | ||||||
23 | to rescind the coverage; and
| ||||||
24 | (D) the effective date of the proposed rescission.
| ||||||
25 | (4) A health carrier may provide the notice required | ||||||
26 | under this Section orally or in writing. If notice of the |
| |||||||
| |||||||
1 | adverse determination is provided orally, then the health | ||||||
2 | carrier shall provide written notice of the adverse | ||||||
3 | determination within 3 days following the oral | ||||||
4 | notification.
| ||||||
5 | Section 5-50. Emergency services. For immediately required | ||||||
6 | post-evaluation or post-stabilization services, a health | ||||||
7 | carrier shall provide access to designated representative 24 | ||||||
8 | hours a day, 7 days a week, to facilitate review.
| ||||||
9 | Section 5-55. Confidentiality requirements. A health | ||||||
10 | carrier shall annually certify in writing to the Director that | ||||||
11 | the utilization review program of the health carrier or its | ||||||
12 | designee complies with all applicable State and federal law | ||||||
13 | establishing confidentiality and reporting requirements.
| ||||||
14 | Section 5-60. Disclosure requirements.
| ||||||
15 | (a) In the certificate of coverage or member handbook | ||||||
16 | provided to covered persons, a health carrier shall include a | ||||||
17 | clear and comprehensive description of its utilization review | ||||||
18 | procedures, including the procedures for obtaining review of | ||||||
19 | adverse determinations, and a statement of rights and | ||||||
20 | responsibilities of covered persons with respect to those | ||||||
21 | procedures.
| ||||||
22 | (b) A health carrier shall include a summary of its | ||||||
23 | utilization review and benefit determination procedures in |
| |||||||
| |||||||
1 | materials intended for prospective covered persons.
| ||||||
2 | (c) A health carrier shall print on its membership cards a | ||||||
3 | toll-free telephone number to call for utilization review and | ||||||
4 | benefit decisions.
| ||||||
5 | Section 5-65. Administration and enforcement. | ||||||
6 | (a) The Director of Insurance may adopt rules necessary to | ||||||
7 | implement the Department's responsibilities under this Law. | ||||||
8 | (b) The Director is authorized to make use of any of the | ||||||
9 | powers established under the Illinois Insurance Code to enforce | ||||||
10 | the laws of this State. This includes but is not limited to, | ||||||
11 | the Director's administrative authority to investigate, issue | ||||||
12 | subpoenas, conduct depositions and hearings, issue orders, | ||||||
13 | including, without limitation, orders pursuant to Article XII | ||||||
14 | 1/2 and Section 401.1 of the Illinois Insurance Code, and | ||||||
15 | impose penalties.
| ||||||
16 | ARTICLE 10. HEALTH CARRIER GRIEVANCE PROCEDURES | ||||||
17 | Section 10-1. Short title. This Article may be cited as the | ||||||
18 | Health Carrier Grievance Procedure Law.
| ||||||
19 | Section 10-5. Purpose and intent. The purpose of this Law | ||||||
20 | is to provide standards for the establishment and maintenance | ||||||
21 | of procedures by health carriers to ensure that covered persons | ||||||
22 | have the opportunity for the appropriate resolution of |
| |||||||
| |||||||
1 | grievances, as defined in this Law.
| ||||||
2 | Section 10-10. Definitions. For purposes of this Law: | ||||||
3 | "Adverse determination" means: | ||||||
4 | (1) a determination by a health carrier or its designee | ||||||
5 | utilization review organization that, based upon the | ||||||
6 | information provided, a request for a benefit under the | ||||||
7 | health carrier's health benefit plan upon application of | ||||||
8 | any utilization review technique does not meet the health | ||||||
9 | carrier's requirements for medical necessity, | ||||||
10 | appropriateness, health care setting, level of care, or | ||||||
11 | effectiveness or is determined to be experimental or | ||||||
12 | investigational and the requested benefit is therefore | ||||||
13 | denied, reduced, or terminated or payment is not provided | ||||||
14 | or made, in whole or in part, for the benefit;
| ||||||
15 | (2) the denial, reduction, termination or failure to | ||||||
16 | provide or make payment, in whole or in part, for a benefit | ||||||
17 | based on a determination by a health carrier or its | ||||||
18 | designee utilization review organization of a covered | ||||||
19 | person's eligibility to participate in the health | ||||||
20 | carrier's health benefit plan;
| ||||||
21 | (3) any prospective review or retrospective review | ||||||
22 | determination that denies, reduces, or terminates or fails | ||||||
23 | to provide or make payment, in whole or in part, for a | ||||||
24 | benefit; or
| ||||||
25 | (4) a rescission of coverage determination.
|
| |||||||
| |||||||
1 | "Ambulatory review" means utilization review of health | ||||||
2 | care services performed or provided in an outpatient setting. | ||||||
3 | "Authorized representative" means: | ||||||
4 | (1) a person to whom a covered person has given express | ||||||
5 | written consent to represent the covered person for | ||||||
6 | purposes of this Law;
| ||||||
7 | (2) a person authorized by law to provide substituted | ||||||
8 | consent for a covered person;
| ||||||
9 | (3) a family member of the covered person or the | ||||||
10 | covered person's treating health care professional when | ||||||
11 | the covered person is unable to provide consent;
| ||||||
12 | (4) a health care provider when the covered person's | ||||||
13 | health benefit plan requires that a request for a benefit | ||||||
14 | under the plan be initiated by the health care provider; or
| ||||||
15 | (5) in the case of an urgent care request, a health | ||||||
16 | care provider with knowledge of the covered person's | ||||||
17 | medical condition.
| ||||||
18 | "Case management" means a coordinated set of activities | ||||||
19 | conducted for individual patient management of serious, | ||||||
20 | complicated, protracted, or other health conditions. | ||||||
21 | "Certification" means a determination by a health carrier | ||||||
22 | or its designee utilization review organization that a request | ||||||
23 | for a benefit under the health carrier's health benefit plan | ||||||
24 | has been reviewed and, based on the information provided, | ||||||
25 | satisfies the health carrier's requirements for medical | ||||||
26 | necessity, appropriateness, health care setting, level of |
| |||||||
| |||||||
1 | care, and effectiveness. | ||||||
2 | "Clinical peer" has the same meaning given that term in the | ||||||
3 | Managed Care Reform and Patients Rights Act. | ||||||
4 | "Clinical review criteria" means the written screening | ||||||
5 | procedures, decision abstracts, clinical protocols, and | ||||||
6 | practice guidelines used by a health carrier to determine the | ||||||
7 | necessity and appropriateness of health care services. | ||||||
8 | "Closed plan" means a managed care plan that requires | ||||||
9 | covered persons to use participating providers under the terms | ||||||
10 | of the managed care plan. | ||||||
11 | "Director" means the Director of Insurance. | ||||||
12 | "Concurrent review" means a review conducted during a | ||||||
13 | patient's stay or course of treatment in a facility, the office | ||||||
14 | of a health care professional, or other inpatient or outpatient | ||||||
15 | health care setting. | ||||||
16 | "Covered benefits" or "benefits" means those health care | ||||||
17 | services to which a covered person is entitled under the terms | ||||||
18 | of a health benefit plan. | ||||||
19 | "Covered person" means a policyholder, subscriber, | ||||||
20 | enrollee, or other individual participating in a health benefit | ||||||
21 | plan. | ||||||
22 | "Discharge planning" means the formal process for | ||||||
23 | determining, prior to discharge from a facility, the | ||||||
24 | coordination and management of the care that a patient receives | ||||||
25 | following discharge from a facility. | ||||||
26 | "Emergency medical condition" means a medical condition |
| |||||||
| |||||||
1 | manifesting itself by acute symptoms of sufficient severity, | ||||||
2 | including severe pain, such that a prudent layperson who | ||||||
3 | possesses an average knowledge of health and medicine could | ||||||
4 | reasonably expect that the absence of immediate medical | ||||||
5 | attention would result in serious impairment to bodily | ||||||
6 | functions, serious dysfunction of a bodily organ or part, or | ||||||
7 | would place the person's health or, with respect to a pregnant | ||||||
8 | woman, the health of the woman or her unborn child in serious | ||||||
9 | jeopardy.
| ||||||
10 | "Emergency services" means, with respect to an emergency | ||||||
11 | medical condition:
| ||||||
12 | (1) a medical screening examination that is within the | ||||||
13 | capability of the emergency department of a hospital, | ||||||
14 | including ancillary services routinely available to the | ||||||
15 | emergency department to evaluate such emergency medical | ||||||
16 | condition; and
| ||||||
17 | (2) such further medical examination and treatment to | ||||||
18 | stabilize a patient, to the extent they are within the | ||||||
19 | capability of the staff and facilities available at a | ||||||
20 | hospital.
| ||||||
21 | "Facility" means an institution providing health care | ||||||
22 | services or a health care setting, including, but not limited | ||||||
23 | to, hospitals and other licensed inpatient centers, ambulatory | ||||||
24 | surgical or treatment centers, skilled nursing centers, | ||||||
25 | residential treatment centers, diagnostic, laboratory and | ||||||
26 | imaging centers, and rehabilitation and other therapeutic |
| |||||||
| |||||||
1 | health settings.
| ||||||
2 | "Final adverse determination" means an adverse | ||||||
3 | determination that has been upheld by the health carrier at the | ||||||
4 | completion of the internal appeals process applicable under | ||||||
5 | Section 10-30 or Section 10-40 of this Law or an adverse | ||||||
6 | determination that with respect to which the internal appeals | ||||||
7 | process has been deemed exhausted in accordance with subsection | ||||||
8 | (b) or (c) of Section 10-25 of this Law.
| ||||||
9 | "Grievance" means a written complaint or oral complaint if | ||||||
10 | the complaint involves an urgent care request submitted by or | ||||||
11 | on behalf of a covered person regarding:
| ||||||
12 | (1) availability, delivery, or quality of health care | ||||||
13 | services, including a complaint regarding an adverse | ||||||
14 | determination made pursuant to utilization review;
| ||||||
15 | (2) claims payment, handling, or reimbursement for | ||||||
16 | health care services; or
| ||||||
17 | (3) matters pertaining to the contractual relationship | ||||||
18 | between a covered person and a health carrier.
| ||||||
19 | "Health benefit plan" means a policy, contract, | ||||||
20 | certificate, or agreement offered or issued by a health carrier | ||||||
21 | to provide, deliver, arrange for, pay for, or reimburse any of | ||||||
22 | the costs of health care services. "Health benefit plan" | ||||||
23 | includes short-term and catastrophic health insurance | ||||||
24 | policies, and policies that pay on a cost-incurred basis, | ||||||
25 | except as otherwise specifically exempted in this definition. | ||||||
26 | "Health benefit plan" does not include: |
| |||||||
| |||||||
1 | (1) coverage only for accident or disability income | ||||||
2 | insurance or any combination thereof;
| ||||||
3 | (2) coverage issued as a supplement to liability | ||||||
4 | insurance;
| ||||||
5 | (3) liability insurance, including general liability | ||||||
6 | insurance and automobile liability insurance;
| ||||||
7 | (4) workers' compensation or similar insurance;
| ||||||
8 | (5) automobile medical payment insurance;
| ||||||
9 | (6) credit-only insurance;
| ||||||
10 | (7) coverage for on-site medical clinics; and
| ||||||
11 | (8) other similar insurance coverage, specified in | ||||||
12 | federal regulations issued pursuant to Pub. L. No. 104-191, | ||||||
13 | under which benefits for medical care are secondary or | ||||||
14 | incidental to other insurance benefits.
| ||||||
15 | "Health benefit plan" does not include the following | ||||||
16 | benefits if they are provided under a separate policy, | ||||||
17 | certificate, or contract of insurance or are otherwise not an | ||||||
18 | integral part of the plan:
| ||||||
19 | (1) limited scope dental or vision benefits;
| ||||||
20 | (2) benefits for long-term care, nursing home care, | ||||||
21 | home health care, community-based care, or any combination | ||||||
22 | thereof; or
| ||||||
23 | (3) other similar, limited benefits specified in | ||||||
24 | federal regulations issued pursuant to Pub. L. No. 104-191.
| ||||||
25 | "Health benefit plan" does not include the following | ||||||
26 | benefits if the benefits are provided under a separate policy, |
| |||||||
| |||||||
1 | certificate, or contract of insurance, there is no coordination | ||||||
2 | between the provision of the benefits and any exclusion of | ||||||
3 | benefits under any group health plan maintained by the same | ||||||
4 | plan sponsor and the benefits are paid with respect to an event | ||||||
5 | without regard to whether benefits are provided with respect to | ||||||
6 | such an event under any group health plan maintained by the | ||||||
7 | same plan sponsor:
| ||||||
8 | (1) coverage only for a specified disease or illness; | ||||||
9 | or
| ||||||
10 | (2) hospital indemnity or other fixed indemnity | ||||||
11 | insurance.
| ||||||
12 | "Health benefit plan" does not include the following if | ||||||
13 | offered as a separate policy, certificate, or contract of | ||||||
14 | insurance:
| ||||||
15 | (1) medicare supplemental health insurance as defined | ||||||
16 | under Section 1882(g)(1) of the Social Security Act;
| ||||||
17 | (2) coverage supplemental to the coverage provided | ||||||
18 | under Chapter 55 of Title 10, United States Code (Civilian | ||||||
19 | Health and Medical Program of the Uniformed Services | ||||||
20 | (CHAMPUS)); or
| ||||||
21 | (3) similar supplemental coverage provided to coverage | ||||||
22 | under a group health plan.
| ||||||
23 | "Health care professional" means a physician or other | ||||||
24 | health care practitioner licensed, accredited, or certified to | ||||||
25 | perform specified health care services consistent with State | ||||||
26 | law.
|
| |||||||
| |||||||
1 | "Health care provider" or "provider" means a health care | ||||||
2 | professional or a facility.
| ||||||
3 | "Health care services" means services for the diagnosis, | ||||||
4 | prevention, treatment, cure, or relief of a health condition, | ||||||
5 | illness, injury, or disease.
| ||||||
6 | "Health carrier" means an entity subject to the insurance | ||||||
7 | laws and regulations of this State, or subject to the | ||||||
8 | jurisdiction of the Director, that contracts or offers to | ||||||
9 | contract to provide, deliver, arrange for, pay for, or | ||||||
10 | reimburse any of the costs of health care services, including a | ||||||
11 | sickness and accident insurance company, a health maintenance | ||||||
12 | organization, a nonprofit hospital and health service | ||||||
13 | corporation, or any other entity providing a plan of health | ||||||
14 | insurance, health benefits or health care services.
| ||||||
15 | "Health indemnity plan" means a health benefit plan that is | ||||||
16 | not a managed care plan.
| ||||||
17 | "Managed care plan" means a health benefit plan that | ||||||
18 | requires a covered person to use or creates incentives, | ||||||
19 | including financial incentives, for a covered person to use | ||||||
20 | health care providers managed, owned, under contract with, or | ||||||
21 | employed by the health carrier. "Managed care plan" includes:
| ||||||
22 | (1) a closed plan, as defined in this Law; and
| ||||||
23 | (2) an open plan, as defined in this Law.
| ||||||
24 | "Network" means the group of participating providers | ||||||
25 | providing services to a managed care plan.
| ||||||
26 | "Open plan" means a managed care plan other than a closed |
| |||||||
| |||||||
1 | plan that provides incentives, including financial incentives, | ||||||
2 | for covered persons to use participating providers under the | ||||||
3 | terms of the managed care plan.
| ||||||
4 | "Person" means an individual, a corporation, a | ||||||
5 | partnership, an association, a joint venture, a joint stock | ||||||
6 | company, a trust, an unincorporated organization, any similar | ||||||
7 | entity, or any combination of the foregoing.
| ||||||
8 | "Prospective review" means a review conducted prior to an | ||||||
9 | admission or the provision of a health care service or a course | ||||||
10 | of treatment in accordance with a health carrier's requirement | ||||||
11 | that the health care service or course of treatment, in whole | ||||||
12 | or in part, be approved prior to its provision.
| ||||||
13 | "Rescission" means a cancellation or discontinuance of | ||||||
14 | coverage under a health benefit plan that has a retroactive | ||||||
15 | effect. "Rescission" does not include a cancellation or | ||||||
16 | discontinuance of coverage under a health benefit plan if:
| ||||||
17 | (1) the cancellation or discontinuance of coverage has | ||||||
18 | only a prospective effect; or
| ||||||
19 | (2) the cancellation or discontinuance of coverage is | ||||||
20 | effective retroactively to the extent it is attributable to | ||||||
21 | a failure to timely pay required premiums or contributions | ||||||
22 | towards the cost of coverage.
| ||||||
23 | "Retrospective review" means any review of a request for a | ||||||
24 | benefit that is not a concurrent or prospective review request. | ||||||
25 | "Retrospective review" does not include the review of a claim | ||||||
26 | that is limited to veracity of documentation or accuracy of |
| |||||||
| |||||||
1 | coding.
| ||||||
2 | "Second opinion" means an opportunity or requirement to | ||||||
3 | obtain a clinical evaluation by a provider other than the one | ||||||
4 | originally making a recommendation for a proposed health care | ||||||
5 | service to assess the medical necessity and appropriateness of | ||||||
6 | the initially proposed health care service.
| ||||||
7 | "Stabilization" has the same meaning given that term in | ||||||
8 | Managed Care Reform and Patient Rights Act.
| ||||||
9 | "Urgent care request" means a request for a health care | ||||||
10 | service or course of treatment with respect to which the time | ||||||
11 | periods for making non-urgent care request determination:
| ||||||
12 | (1) could seriously jeopardize the life or health of | ||||||
13 | the covered person or the ability of the covered person to | ||||||
14 | regain maximum function; or
| ||||||
15 | (2) in the opinion of a physician with knowledge of the | ||||||
16 | covered person's medical condition, would subject the | ||||||
17 | covered person to severe pain that cannot be adequately | ||||||
18 | managed without the health care service or treatment that | ||||||
19 | is the subject of the request.
| ||||||
20 | Except as provided in item (2) of this definition of | ||||||
21 | "urgent care request", in determining whether a request is to | ||||||
22 | be treated as an urgent care request, an individual acting on | ||||||
23 | behalf of the health carrier shall apply the judgment of a | ||||||
24 | prudent layperson who possesses an average knowledge of health | ||||||
25 | and medicine.
| ||||||
26 | Any request that a physician with knowledge of the covered |
| |||||||
| |||||||
1 | person's medical condition determines is an urgent care request | ||||||
2 | shall be treated as an urgent care request.
| ||||||
3 | "Utilization review" has the same meaning given that term | ||||||
4 | in Managed Care Reform and Patient Rights Act.
| ||||||
5 | "Utilization review organization" means a utilization | ||||||
6 | review program as defined in the Managed Care Reform and | ||||||
7 | Patient Rights Act.
| ||||||
8 | Section 10-15. Applicability and scope. Except as | ||||||
9 | otherwise specified, this Law shall apply to all health | ||||||
10 | carriers offering a health benefit plan.
| ||||||
11 | Section 10-20. Grievance reporting and record-keeping | ||||||
12 | requirements. | ||||||
13 | (a) A health carrier shall maintain written records to | ||||||
14 | document all grievances received, including the notices and | ||||||
15 | claims associated with the grievances, during a calendar year.
| ||||||
16 | (b) Notwithstanding the provisions under subsections (g) | ||||||
17 | and (h) of this Section, a health carrier shall maintain the | ||||||
18 | records required under subsection (a) of this Section for at | ||||||
19 | least 6 years related to the notices provided under subsection | ||||||
20 | (g) of Section 10-30 and subsection (h) of Section 10-40 of | ||||||
21 | this Law.
| ||||||
22 | (c) The health carrier shall make the records available for | ||||||
23 | examination by covered persons and the Director upon request, | ||||||
24 | and shall annually file a copy of the register with the |
| |||||||
| |||||||
1 | Department. The Department shall make a summary of all data | ||||||
2 | collected available upon request and shall publish the summary | ||||||
3 | on the World Wide Web. No Department publication or release of | ||||||
4 | information shall identify any enrollee, health care provider, | ||||||
5 | or individual complainant.
| ||||||
6 | (d) A request for a review of a grievance involving an | ||||||
7 | adverse determination shall be processed in compliance with | ||||||
8 | Section 10-30 of this Law and shall be included in the | ||||||
9 | register.
| ||||||
10 | (e) For each grievance the register shall contain, at a | ||||||
11 | minimum, the following information:
| ||||||
12 | (1) an indication regarding whether the grievance was | ||||||
13 | filed by:
| ||||||
14 | (A) a consumer or enrollee;
| ||||||
15 | (B) a provider; or
| ||||||
16 | (C) any other individual;
| ||||||
17 | (2) classification of the grievance under one of the | ||||||
18 | following categories:
| ||||||
19 | (A) denial of care or treatment;
| ||||||
20 | (B) denial of a diagnostic procedure;
| ||||||
21 | (C) denial of a referral request;
| ||||||
22 | (D) sufficient choice and accessibility of health | ||||||
23 | care providers;
| ||||||
24 | (E) underwriting;
| ||||||
25 | (F) marketing and sales;
| ||||||
26 | (G) claims and utilization review;
|
| |||||||
| |||||||
1 | (H) member services;
| ||||||
2 | (I) provider relations; and
| ||||||
3 | (J) miscellaneous;
| ||||||
4 | (3) a general description of the reason for the | ||||||
5 | grievance;
| ||||||
6 | (4) the date received;
| ||||||
7 | (5) the date of each review or, if applicable, review | ||||||
8 | meeting;
| ||||||
9 | (6) resolution at each level of the grievance, if | ||||||
10 | applicable;
| ||||||
11 | (7) the date of resolution at each level, if | ||||||
12 | applicable; and
| ||||||
13 | (8) the name of the covered person for whom the | ||||||
14 | grievance was filed.
| ||||||
15 | (f) The register shall be maintained in a manner that is | ||||||
16 | reasonably clear and accessible to the Director.
| ||||||
17 | (g) Subject to the provisions of subsection (a) of this | ||||||
18 | Section, a health carrier shall retain the register compiled | ||||||
19 | for a calendar year for the longer of 3 years or until the | ||||||
20 | Director has adopted a final report of an examination that | ||||||
21 | contains a review of the register for that calendar year.
| ||||||
22 | (h) A health carrier shall submit to the Director, at least | ||||||
23 | annually, a report in the format specified by the Director. The | ||||||
24 | report shall include for each type of health benefit plan | ||||||
25 | offered by the health carrier:
| ||||||
26 | (1) the certificate of compliance required by Section |
| |||||||
| |||||||
1 | 10-25 of this Law;
| ||||||
2 | (2) the number of covered lives;
| ||||||
3 | (3) the total number of grievances;
| ||||||
4 | (4) the number of grievances resolved at each level, if | ||||||
5 | applicable, and their resolution;
| ||||||
6 | (5) the number of grievances appealed to the Director | ||||||
7 | of which the health carrier has been informed;
| ||||||
8 | (6) the number of grievances referred to alternative | ||||||
9 | dispute resolution procedures or resulting in litigation; | ||||||
10 | and
| ||||||
11 | (7) a synopsis of actions being taken to correct | ||||||
12 | problems identified.
| ||||||
13 | Section 10-25. Grievance review procedures. | ||||||
14 | (a) Except as specified in Section 10-40 of this Law, a | ||||||
15 | health carrier shall use written procedures for receiving and | ||||||
16 | resolving grievances from covered persons, as provided in | ||||||
17 | Sections 10-30 and 10-35 of this Law. | ||||||
18 | (b) The following provisions shall apply: | ||||||
19 | (1) Whenever a health carrier fails to strictly adhere | ||||||
20 | to the requirements of Section 10-30 or Section 10-40 of | ||||||
21 | this Law with respect to receiving and resolving grievances | ||||||
22 | involving an adverse determination, the covered person | ||||||
23 | shall be deemed to have exhausted the provisions of this | ||||||
24 | Law and may take action under paragraph (2) of this | ||||||
25 | subsection (b) regardless of whether the health carrier |
| |||||||
| |||||||
1 | asserts that it substantially complied with the | ||||||
2 | requirements of Section 10-30 or Section 10-40, as | ||||||
3 | applicable, or that any error it committed was de minimus. | ||||||
4 | (2) A covered person may file a request for external | ||||||
5 | review in accordance with the procedures outlined in the | ||||||
6 | Health Carrier External Review Act. In addition, a covered | ||||||
7 | person is entitled to pursue any available remedies under | ||||||
8 | State or federal law on the basis that the health carrier | ||||||
9 | failed to provide a reasonable internal claims and appeals | ||||||
10 | process that would yield a decision on the merits of the | ||||||
11 | claim. | ||||||
12 | (c) A health carrier shall file a copy of the procedures | ||||||
13 | required under subsections (a) and (b) of this Section, | ||||||
14 | including all forms used to process requests made pursuant to | ||||||
15 | Sections 10-30 and 10-35 of this Law, with the Director. Any | ||||||
16 | subsequent modifications to the documents also shall be filed. | ||||||
17 | (d) The Director may disapprove a filing received in | ||||||
18 | accordance with subsection (c) of this Section that fails to | ||||||
19 | comply with this Law or applicable regulations. | ||||||
20 | (e) A health carrier shall file annually with the Director, | ||||||
21 | as part of its annual report required by Section 10-20 of this | ||||||
22 | Law, a certificate of compliance stating that the health | ||||||
23 | carrier has established and maintains, for each of its health | ||||||
24 | benefit plans, grievance procedures that fully comply with the | ||||||
25 | provisions of this Law. | ||||||
26 | (f) A description of the grievance procedures required |
| |||||||
| |||||||
1 | under this Section shall be set forth in or attached to the | ||||||
2 | policy, certificate, membership booklet, outline of coverage | ||||||
3 | or other evidence of coverage provided to covered persons. | ||||||
4 | (g) The grievance procedure documents shall include a | ||||||
5 | statement of a covered person's right to contact the Department | ||||||
6 | or the Office of Consumer Health Insurance for assistance at | ||||||
7 | any time. The statement shall include the telephone number and | ||||||
8 | address of the Department and the Office of Consumer Health | ||||||
9 | Insurance.
| ||||||
10 | Section 10-30. Reviews of grievances involving an adverse | ||||||
11 | determination. | ||||||
12 | (a) Within 180 days after the date of receipt of a notice | ||||||
13 | of an adverse determination sent pursuant to the Managed Care | ||||||
14 | Reform and Patient Rights Act, a covered person or the covered | ||||||
15 | person's authorized representative may file a grievance with | ||||||
16 | the health carrier requesting a review of the adverse | ||||||
17 | determination. | ||||||
18 | (b) The health carrier shall provide the covered person | ||||||
19 | with the name, address, and telephone number of a person or | ||||||
20 | organizational unit designated to coordinate the review on | ||||||
21 | behalf of the health carrier. | ||||||
22 | (c) In providing for a review under this Section, the | ||||||
23 | health carrier shall ensure that the review is conducted in a | ||||||
24 | manner under this Section to ensure the independence and | ||||||
25 | impartiality of the individuals involved in making the review |
| |||||||
| |||||||
1 | decision. | ||||||
2 | (d) In ensuring the independence and impartially of | ||||||
3 | individuals involved in making the review decision, the health | ||||||
4 | carrier shall not make decisions related to such individuals | ||||||
5 | regarding hiring, compensation, termination, promotion, or | ||||||
6 | other similar matters based upon the likelihood that the | ||||||
7 | individual will support the denial of benefits. | ||||||
8 | (e) In the case of an adverse determination involving | ||||||
9 | utilization review, the health carrier shall designate an | ||||||
10 | appropriate clinical peer or peers of the same or similar | ||||||
11 | specialty as would typically manage the case being reviewed to | ||||||
12 | review the adverse determination. The clinical peer shall not | ||||||
13 | have been involved in the initial adverse determination. | ||||||
14 | (f) In designating an appropriate clinical peer or peers | ||||||
15 | pursuant to subsection (e) of this Section, the health carrier | ||||||
16 | shall ensure that, if more than one clinical peer is involved | ||||||
17 | in the review, a majority of the individuals reviewing the | ||||||
18 | adverse determination are health care professionals who have | ||||||
19 | appropriate expertise. | ||||||
20 | (g) In conducting a review under this Section, the reviewer | ||||||
21 | or reviewers shall take into consideration all comments, | ||||||
22 | documents, records, and other information regarding the | ||||||
23 | request for services submitted by the covered person or the | ||||||
24 | covered person's authorized representative, without regard to | ||||||
25 | whether the information was submitted or considered in making | ||||||
26 | the initial adverse determination. |
| |||||||
| |||||||
1 | (h) A covered person does not have the right to attend or | ||||||
2 | to have a representative in attendance at the review, but the | ||||||
3 | covered person or, if applicable, the covered person's | ||||||
4 | authorized representative is entitled to: | ||||||
5 | (1) submit written comments, documents, records, and | ||||||
6 | other material relating to the request for benefits for the | ||||||
7 | reviewer or reviewers to consider when conducting the | ||||||
8 | review; and | ||||||
9 | (2) receive from the health carrier, upon request and | ||||||
10 | free of charge, reasonable access to and copies of all | ||||||
11 | documents, records, and other information relevant to the | ||||||
12 | covered person's request for benefits. | ||||||
13 | (i) For purposes of paragraph (2) of subsection (h) of this | ||||||
14 | Section, a document, record, or other information shall be | ||||||
15 | considered "relevant" to a covered person's request for | ||||||
16 | benefits if the document, record, or other information: | ||||||
17 | (1) was relied upon in making the benefit | ||||||
18 | determination; | ||||||
19 | (2) was submitted, considered, or generated in the | ||||||
20 | course of making the adverse determination, without regard | ||||||
21 | to whether the document, record, or other information was | ||||||
22 | relied upon in making the benefit determination; | ||||||
23 | (3) demonstrates that, in making the benefit | ||||||
24 | determination, the health carrier or its designated | ||||||
25 | representatives consistently applied required | ||||||
26 | administrative procedures and safeguards with respect to |
| |||||||
| |||||||
1 | the covered person as other similarly situated covered | ||||||
2 | persons; or | ||||||
3 | (4) constitutes a statement of policy or guidance with | ||||||
4 | respect to the health benefit plan concerning the denied | ||||||
5 | health care service or treatment for the covered person's | ||||||
6 | diagnosis, without regard to whether the advice or | ||||||
7 | statement was relied upon in making the benefit | ||||||
8 | determination. | ||||||
9 | (j) The health carrier shall make the provisions of | ||||||
10 | subsections (h) and (i) of this Section known to the covered | ||||||
11 | person or, if applicable, the covered person's authorized | ||||||
12 | representative within 3 business days after the date of receipt | ||||||
13 | of the grievance. | ||||||
14 | (k) For purposes of calculating the time periods within | ||||||
15 | which a determination is required to be made and notice | ||||||
16 | provided under subsections (l), (m), and (n) of this Section, | ||||||
17 | the time period shall begin on the date the grievance | ||||||
18 | requesting the review is filed with the health carrier in | ||||||
19 | accordance with the health carrier's procedures established | ||||||
20 | pursuant to Section 10-25 of this Law for filing a request | ||||||
21 | without regard to whether all of the information necessary to | ||||||
22 | make the determination accompanies the filing. | ||||||
23 | (l) A health carrier shall notify and issue a decision in | ||||||
24 | writing or electronically to the covered person or, if | ||||||
25 | applicable, the covered person's authorized representative | ||||||
26 | within the time frames provided in subsection (m) or (n) of |
| |||||||
| |||||||
1 | this Section. | ||||||
2 | (m) With respect to a grievance requesting a review of an | ||||||
3 | adverse determination involving a prospective review request, | ||||||
4 | the health carrier shall notify and issue a decision within a | ||||||
5 | reasonable period of time that is appropriate given the covered | ||||||
6 | person's medical condition, but no later than 30 days after the | ||||||
7 | date of the health carrier's receipt of the grievance | ||||||
8 | requesting the review made pursuant to subsection (a) of this | ||||||
9 | Section. | ||||||
10 | (n) With respect to a grievance requesting a review of an | ||||||
11 | adverse determination involving a retrospective review | ||||||
12 | request, the health carrier shall notify and issue a decision | ||||||
13 | within a reasonable period of time, but no later than 60 days | ||||||
14 | after the date of the health carrier's receipt of the grievance | ||||||
15 | requesting the review made pursuant to subsection (a) of this | ||||||
16 | Section. | ||||||
17 | (o) Prior to issuing a decision in accordance with the | ||||||
18 | timeframes provided in subsection (m) or (n) of this Section, | ||||||
19 | the health carrier shall provide free of charge to the covered | ||||||
20 | person, or the covered person's authorized representative, any | ||||||
21 | new or additional evidence relied upon or generated by the | ||||||
22 | health carrier or at the direction of the health carrier, in | ||||||
23 | connection with the grievance sufficiently in advance of the | ||||||
24 | date the decision is required to be provided to permit the | ||||||
25 | covered person or the covered person's authorized | ||||||
26 | representative, a reasonable opportunity to respond prior to |
| |||||||
| |||||||
1 | that date. | ||||||
2 | (p) Before the health carrier issues or provides notice of | ||||||
3 | a final adverse determination in accordance with the timeframes | ||||||
4 | provided in subsection (m) or (n) of this Section that is based | ||||||
5 | on new or additional rationale, the health carrier shall | ||||||
6 | provide the new or additional rationale to the covered person | ||||||
7 | or the covered person's authorized representative free of | ||||||
8 | charge as soon as possible and sufficiently in advance of the | ||||||
9 | date the notice of final adverse determination is to be | ||||||
10 | provided to permit the covered person or the covered person's | ||||||
11 | authorized representative a reasonable opportunity to respond | ||||||
12 | prior to that date. | ||||||
13 | The decision issued pursuant to subsection (m) or (n) of | ||||||
14 | this Section shall set forth the following in a manner | ||||||
15 | calculated to be understood by the covered person or, if | ||||||
16 | applicable, the covered person's authorized representative: | ||||||
17 | (1) the titles and qualifying credentials of the person | ||||||
18 | or persons participating in the review process (the | ||||||
19 | reviewers); | ||||||
20 | (2) information sufficient to identify the claim | ||||||
21 | involved with respect to the grievance, including the date | ||||||
22 | of service, the health care provider, if applicable, the | ||||||
23 | claim amount, the diagnosis code and its corresponding | ||||||
24 | meaning, and the treatment code and its corresponding | ||||||
25 | meaning; | ||||||
26 | (3) a statement of the reviewers' understanding of the |
| |||||||
| |||||||
1 | covered person's grievance; | ||||||
2 | (4) the reviewers' decision in clear terms and the | ||||||
3 | contract basis or medical rationale in sufficient detail | ||||||
4 | for the covered person to respond further to the health | ||||||
5 | carrier's position; | ||||||
6 | (5) a reference to the evidence or documentation used | ||||||
7 | as the basis for the decision; | ||||||
8 | (6) for a decision issued pursuant to this Section that | ||||||
9 | upholds the grievance: | ||||||
10 | (A) the specific reason or reasons for the final | ||||||
11 | adverse determination, including the denial code and | ||||||
12 | its corresponding meaning, as well as a description of | ||||||
13 | the health carrier's standard, if any, that was used in | ||||||
14 | reaching the denial; | ||||||
15 | (B) the reference to the specific plan provisions | ||||||
16 | on which the determination is based; | ||||||
17 | (C) a statement that the covered person is entitled | ||||||
18 | to receive, upon request and free of charge, reasonable | ||||||
19 | access to and copies of all documents, records, and | ||||||
20 | other information relevant, as the term "relevant" is | ||||||
21 | defined in subsection (i) of this Section, to the | ||||||
22 | covered person's benefit request; | ||||||
23 | (D) if the health carrier relied upon an internal | ||||||
24 | rule, guideline, protocol, or other similar criterion | ||||||
25 | to make the final adverse determination, either the | ||||||
26 | specific rule, guideline, protocol, or other similar |
| |||||||
| |||||||
1 | criterion or a statement that a specific rule, | ||||||
2 | guideline, protocol, or other similar criterion was | ||||||
3 | relied upon to make the final adverse determination and | ||||||
4 | that a copy of the rule, guideline, protocol, or other | ||||||
5 | similar criterion will be provided free of charge to | ||||||
6 | the covered person upon request; | ||||||
7 | (E) if the final adverse determination is based on | ||||||
8 | a medical necessity or experimental or investigational | ||||||
9 | treatment or similar exclusion or limit, either an | ||||||
10 | explanation of the scientific or clinical judgment for | ||||||
11 | making the determination, applying the terms of the | ||||||
12 | health benefit plan to the covered person's medical | ||||||
13 | circumstances or a statement that an explanation will | ||||||
14 | be provided to the covered person free of charge upon | ||||||
15 | request; and | ||||||
16 | (F) if applicable, instructions for requesting: | ||||||
17 | (i) a copy of the rule, guideline, protocol or | ||||||
18 | other similar criterion relied upon in making the | ||||||
19 | final adverse determination, as provided in | ||||||
20 | subparagraph (D) of paragraph (6) of subsection | ||||||
21 | (p) of this Section; and | ||||||
22 | (ii) the written statement of the scientific | ||||||
23 | or clinical rationale for the determination, as | ||||||
24 | provided in subparagraph (E) of paragraph (6) of | ||||||
25 | subsection (p) of this Section; | ||||||
26 | (G) If applicable, a statement indicating: |
| |||||||
| |||||||
1 | (i) a description of the procedures for | ||||||
2 | obtaining an independent external review of the | ||||||
3 | final adverse determination pursuant to the Health | ||||||
4 | Carrier External Review Act; and | ||||||
5 | (ii) the covered person's right to bring a | ||||||
6 | civil action in a court of competent jurisdiction; | ||||||
7 | and | ||||||
8 | (iii) notice of the covered person's right to | ||||||
9 | contact the Department or the Office of Consumer | ||||||
10 | Health Insurance for assistance with respect to | ||||||
11 | any claim, grievance, or appeal at any time, | ||||||
12 | including the telephone number and address of the | ||||||
13 | Department and the Office of Consumer Health | ||||||
14 | Insurance. | ||||||
15 | (q) A health carrier shall provide the notice required | ||||||
16 | under subsection (p) of this Section in a culturally and | ||||||
17 | linguistically appropriate manner if required in accordance | ||||||
18 | with federal regulations. If a health carrier is required to | ||||||
19 | provide the notice in a culturally and linguistically | ||||||
20 | appropriate manner in accordance with federal regulations, | ||||||
21 | then the health carrier shall: | ||||||
22 | (1) include a statement in the English version of the | ||||||
23 | notice, prominently displayed in the non-English language, | ||||||
24 | offering the provision of the notice in the non-English | ||||||
25 | language; | ||||||
26 | (2) once a utilization review or benefit determination |
| |||||||
| |||||||
1 | request has been made by a covered person, provide all | ||||||
2 | subsequent notices to the covered person in the non-English | ||||||
3 | language; and | ||||||
4 | (3) to the extent the health carrier maintains a | ||||||
5 | consumer assistance process, such as a telephone hotline | ||||||
6 | that answers questions or provides assistance with filing | ||||||
7 | claims and appeals, the health carrier shall provide this | ||||||
8 | assistance in the non-English language.
| ||||||
9 | Section 10-35. Standard reviews of grievances not | ||||||
10 | involving an adverse determination. | ||||||
11 | (a) A health carrier shall establish written procedures for | ||||||
12 | a standard review of a grievance that does not involve an | ||||||
13 | adverse determination. | ||||||
14 | (b) The procedures shall permit a covered person or the | ||||||
15 | covered person's authorized representative to file a grievance | ||||||
16 | that does not involve an adverse determination with the health | ||||||
17 | carrier under this Section. | ||||||
18 | (c) A covered person does not have the right to attend or | ||||||
19 | to have a representative in attendance at the standard review, | ||||||
20 | but the covered person or the covered person's authorized | ||||||
21 | representative is entitled to submit written material for the | ||||||
22 | person or persons designated by the carrier pursuant to | ||||||
23 | subsection (e) of this Section to consider when conducting the | ||||||
24 | review. | ||||||
25 | (d) The health carrier shall make the provisions of |
| |||||||
| |||||||
1 | subsection (c) of this Section known to the covered person or, | ||||||
2 | if applicable, the covered person's authorized representative | ||||||
3 | within 3 business days after the date of receiving the | ||||||
4 | grievance. | ||||||
5 | (e) Upon receipt of the grievance, a health carrier shall | ||||||
6 | designate a person or persons to conduct the standard review of | ||||||
7 | the grievance. The health carrier shall not designate the same | ||||||
8 | person or persons to conduct the standard review of the | ||||||
9 | grievance that denied the claim or handled the matter that is | ||||||
10 | the subject of the grievance. The health carrier shall provide | ||||||
11 | the covered person or, if applicable, the covered person's | ||||||
12 | authorized representative with the name, address, and | ||||||
13 | telephone number of a person designated to coordinate the | ||||||
14 | standard review on behalf of the health carrier. | ||||||
15 | (f) The health carrier shall notify in writing the covered | ||||||
16 | person or, if applicable, the covered person's authorized | ||||||
17 | representative of the decision within 20 business days after | ||||||
18 | the date of receipt of the request for a standard review of a | ||||||
19 | grievance filed pursuant to this Section. | ||||||
20 | (g) Subject to subsection (h) of this Section, if, due to | ||||||
21 | circumstances beyond the carrier's control, the health carrier | ||||||
22 | cannot make a decision and notify the covered person or, if | ||||||
23 | applicable, the covered person's authorized representative | ||||||
24 | pursuant to subsection (f) of this Section within 20 business | ||||||
25 | days, the health carrier may take up to an additional 10 | ||||||
26 | business days to issue a written decision. |
| |||||||
| |||||||
1 | (h) A health carrier may extend the time for making and | ||||||
2 | notifying the covered person or, if applicable, the covered | ||||||
3 | person's authorized representative in accordance with | ||||||
4 | subsection (g) of this Section, if, on or before the 20th | ||||||
5 | business day after the date of receiving the request for a | ||||||
6 | standard review of a grievance, the health carrier provides | ||||||
7 | written notice to the covered person or, if applicable, the | ||||||
8 | covered person's authorized representative of the extension | ||||||
9 | and the reasons for the delay. | ||||||
10 | (i) The written decision issued pursuant to this Section | ||||||
11 | shall contain all of the following: | ||||||
12 | (1) The titles and qualifying credentials of the person | ||||||
13 | or persons participating in the standard review process | ||||||
14 | (the reviewers). | ||||||
15 | (2) A statement of the reviewers' understanding of the | ||||||
16 | covered person's grievance. | ||||||
17 | (3) The reviewers' decision in clear terms and the | ||||||
18 | contract basis in sufficient detail for the covered person | ||||||
19 | to respond further to the health carrier's position. | ||||||
20 | (4) Reference to the evidence or documentation used as | ||||||
21 | the basis for the decision. | ||||||
22 | (5) Notice of the covered person's right, at any time, | ||||||
23 | to contact the Department or the Office of Consumer Health | ||||||
24 | Insurance, including the telephone number and address of | ||||||
25 | the Department and the Office of Consumer Health Insurance.
|
| |||||||
| |||||||
1 | Section 10-40. Expedited reviews of grievances involving | ||||||
2 | an adverse determination. | ||||||
3 | (a) A health carrier shall establish written procedures for | ||||||
4 | the expedited review of urgent care requests of grievances | ||||||
5 | involving an adverse determination. | ||||||
6 | (b) In addition to subsection (a) of this Section, a health | ||||||
7 | carrier shall provide an expedited review of a grievance | ||||||
8 | involving an adverse determination with respect to concurrent | ||||||
9 | review urgent care requests involving an admission, | ||||||
10 | availability of care, continued stay or health care service for | ||||||
11 | a covered person who has received emergency services, but has | ||||||
12 | not been discharged from a facility. | ||||||
13 | (c) The procedures shall allow a covered person or the | ||||||
14 | covered person's authorized representative to request an | ||||||
15 | expedited review under this Section orally or in writing. | ||||||
16 | (d) A health carrier shall appoint an appropriate clinical | ||||||
17 | peer or peers in the same or similar specialty as would | ||||||
18 | typically manage the case being reviewed to review the adverse | ||||||
19 | determination. The clinical peer or peers shall not have been | ||||||
20 | involved in making the initial adverse determination. | ||||||
21 | (e) In an expedited review, all necessary information, | ||||||
22 | including the health carrier's decision, shall be transmitted | ||||||
23 | between the health carrier and the covered person or, if | ||||||
24 | applicable, the covered person's authorized representative by | ||||||
25 | telephone, facsimile, or the most expeditious method | ||||||
26 | available. |
| |||||||
| |||||||
1 | (f) An expedited review decision shall be made and the | ||||||
2 | covered person or, if applicable, the covered person's | ||||||
3 | authorized representative shall be notified of the decision in | ||||||
4 | accordance with this Section as expeditiously as the covered | ||||||
5 | person's medical condition requires, but in no event more than | ||||||
6 | 48 hours after the receipt of the request for the expedited | ||||||
7 | review. If the expedited review is of a grievance involving an | ||||||
8 | adverse determination with respect to a concurrent review | ||||||
9 | urgent care request, the service shall be continued without | ||||||
10 | liability to the covered person until the covered person has | ||||||
11 | been notified of the determination. | ||||||
12 | (g) For purposes of calculating the time periods within | ||||||
13 | which a decision is required to be made under subsection (f) of | ||||||
14 | this Section, the time period within which the decision is | ||||||
15 | required to be made shall begin on the date the request is | ||||||
16 | filed with the health carrier in accordance with the health | ||||||
17 | carrier's procedures established pursuant to Section 10-25 of | ||||||
18 | this Law for filing a request without regard to whether all of | ||||||
19 | the information necessary to make the determination | ||||||
20 | accompanies the filing. | ||||||
21 | (h) A notification of a decision under this Section shall, | ||||||
22 | in a manner calculated to be understood by the covered person | ||||||
23 | or, if applicable, the covered person's authorized | ||||||
24 | representative, set forth: | ||||||
25 | (1) the titles and qualifying credentials of the person | ||||||
26 | or persons participating in the expedited review process |
| |||||||
| |||||||
1 | (the reviewers); | ||||||
2 | (2) information sufficient to identify the claim | ||||||
3 | involved with respect to the grievance, including the date | ||||||
4 | of service, the health care provider, if applicable, the | ||||||
5 | claim amount, the diagnosis code and its corresponding | ||||||
6 | meaning, and the treatment code and its corresponding | ||||||
7 | meaning; | ||||||
8 | (3) a statement of the reviewers' understanding of the | ||||||
9 | covered person's grievance; | ||||||
10 | (4) the reviewers' decision in clear terms and the | ||||||
11 | contract basis or medical rationale in sufficient detail | ||||||
12 | for the covered person to respond further to the health | ||||||
13 | carrier's position; | ||||||
14 | (5) a reference to the evidence or documentation used | ||||||
15 | as the basis for the decision; and | ||||||
16 | (6) if the decision involves a final adverse | ||||||
17 | determination, then the notice shall provide: | ||||||
18 | (A) the specific reasons or reasons for the final | ||||||
19 | adverse determination, including the denial code and | ||||||
20 | its corresponding meaning, as well as a description of | ||||||
21 | the health carrier's standard, if any, that was used in | ||||||
22 | reaching the denial; | ||||||
23 | (B) reference to the specific plan provisions on | ||||||
24 | which the determination is based; | ||||||
25 | (C) a description of any additional material or | ||||||
26 | information necessary for the covered person to |
| |||||||
| |||||||
1 | complete the request, including an explanation of why | ||||||
2 | the material or information is necessary to complete | ||||||
3 | the request; | ||||||
4 | (D) if the health carrier relied upon an internal | ||||||
5 | rule, guideline, protocol, or other similar criterion | ||||||
6 | to make the adverse determination, then either the | ||||||
7 | specific rule, guideline, protocol, or other similar | ||||||
8 | criterion or a statement that a specific rule, | ||||||
9 | guideline, protocol, or other similar criterion was | ||||||
10 | relied upon to make the adverse determination and that | ||||||
11 | a copy of the rule, guideline, protocol, or other | ||||||
12 | similar criterion will be provided free of charge to | ||||||
13 | the covered person upon request; | ||||||
14 | (E) if the final adverse determination is based on | ||||||
15 | a medical necessity or experimental or investigational | ||||||
16 | treatment or similar exclusion or limit, then either an | ||||||
17 | explanation of the scientific or clinical judgment for | ||||||
18 | making the determination, applying the terms of the | ||||||
19 | health benefit plan to the covered person's medical | ||||||
20 | circumstances or a statement that an explanation will | ||||||
21 | be provided to the covered person free of charge upon | ||||||
22 | request; | ||||||
23 | (F) If applicable, instructions for requesting: | ||||||
24 | (i) a copy of the rule, guideline, protocol or | ||||||
25 | other similar criterion relied upon in making the | ||||||
26 | adverse determination in accordance with |
| |||||||
| |||||||
1 | subparagraph (4) of paragraph (F) of subsection | ||||||
2 | (h) of this Section; or | ||||||
3 | (ii) the written statement of the scientific | ||||||
4 | or clinical rationale for the adverse | ||||||
5 | determination in accordance with subparagraph (5) | ||||||
6 | of paragraph (F) of subsection (h) of this Section; | ||||||
7 | (G) a statement describing the procedures for | ||||||
8 | obtaining an independent external review of the | ||||||
9 | adverse determination pursuant to the Health Carrier | ||||||
10 | External Review Act; | ||||||
11 | (H) a statement indicating the covered person's | ||||||
12 | right to bring a civil action in a court of competent | ||||||
13 | jurisdiction; and | ||||||
14 | (I) a notice of the covered person's right to | ||||||
15 | contact the Department or the Office of Consumer Health | ||||||
16 | Insurance for assistance with respect to the claim, | ||||||
17 | grievance or appeal at any time, including the | ||||||
18 | telephone number and address of the Department and the | ||||||
19 | Office of Consumer Health Insurance. | ||||||
20 | (i) A health carrier shall provide the notice required | ||||||
21 | under this Section in a culturally and linguistically | ||||||
22 | appropriate manner if required in accordance with federal | ||||||
23 | regulations. | ||||||
24 | (j) If a health carrier is required to provide the notice | ||||||
25 | required under this Section in a culturally and linguistically | ||||||
26 | appropriate manner in accordance with federal regulations, |
| |||||||
| |||||||
1 | then the health carrier shall: | ||||||
2 | (1) include a statement in the English version of the | ||||||
3 | notice, prominently displayed in the non-English language, | ||||||
4 | offering the provision of the notice in the non- English | ||||||
5 | language; | ||||||
6 | (2) once a utilization review or benefit determination | ||||||
7 | request has been made by a covered person, provide all | ||||||
8 | subsequent notices to the covered person in the non- | ||||||
9 | English language; and | ||||||
10 | (3) to the extent the health carrier maintains a | ||||||
11 | consumer assistance process, such as a telephone hotline | ||||||
12 | that answers questions or provides assistance with filing | ||||||
13 | claims and appeals, the health carrier shall provide this | ||||||
14 | assistance in the non-English language. | ||||||
15 | (k) A health carrier may provide the notice required under | ||||||
16 | this Section orally, in writing, or electronically. | ||||||
17 | (l) If notice of the adverse determination is provided | ||||||
18 | orally, then the health carrier shall provide written or | ||||||
19 | electronic notice of the adverse determination within 3 days | ||||||
20 | following the oral notification.
| ||||||
21 | Section 10-45. Administration and enforcement. | ||||||
22 | (a) The Director of Insurance may adopt rules necessary to | ||||||
23 | implement the Department's responsibilities under this Law. | ||||||
24 | (b) The Director is authorized to make use of any of the | ||||||
25 | powers established under the Illinois Insurance Code to enforce |
| |||||||
| |||||||
1 | the laws of this State. This includes but is not limited to, | ||||||
2 | the Director's administrative authority to investigate, issue | ||||||
3 | subpoenas, conduct depositions and hearings, issue orders, | ||||||
4 | including, without limitation, orders pursuant to Article XII | ||||||
5 | 1/2 and Section 401.1 of the Illinois Insurance Code, and | ||||||
6 | impose penalties.
| ||||||
7 | ARTICLE 90. AMENDATORY PROVISIONS | ||||||
8 | Section 90-5. The Managed Care Reform and Patient Rights | ||||||
9 | Act is amended by changing Sections 10, 45, and 85 as follows:
| ||||||
10 | (215 ILCS 134/10)
| ||||||
11 | Sec. 10. Definitions:
| ||||||
12 | "Adverse determination" has the same meaning given that | ||||||
13 | term in the Health Carrier Grievance Procedure Law means a | ||||||
14 | determination by a health care plan under
Section 45 or by a | ||||||
15 | utilization review program under Section
85 that
a health care | ||||||
16 | service is not medically necessary .
| ||||||
17 | "Clinical peer" means a health care professional who is in | ||||||
18 | the same
profession and the same or similar specialty as the | ||||||
19 | health care provider who
typically manages the medical | ||||||
20 | condition, procedures, or treatment under
review.
| ||||||
21 | "Covered person" has the same meaning given that term in | ||||||
22 | the Health Carrier Grievance Procedure Law. | ||||||
23 | "Department" means the Department of Insurance.
|
| |||||||
| |||||||
1 | "Emergency medical condition" means a medical condition | ||||||
2 | manifesting itself by
acute symptoms of sufficient severity | ||||||
3 | (including, but not limited to, severe
pain) such that a | ||||||
4 | prudent
layperson, who possesses an average knowledge of health | ||||||
5 | and medicine, could
reasonably expect the absence of immediate | ||||||
6 | medical attention to result in:
| ||||||
7 | (1) placing the health of the individual (or, with | ||||||
8 | respect to a pregnant
woman, the
health of the woman or her | ||||||
9 | unborn child) in serious jeopardy;
| ||||||
10 | (2) serious
impairment to bodily functions; or
| ||||||
11 | (3) serious dysfunction of any bodily organ
or part.
| ||||||
12 | "Emergency medical screening examination" means a medical | ||||||
13 | screening
examination and
evaluation by a physician licensed to | ||||||
14 | practice medicine in all its branches, or
to the extent | ||||||
15 | permitted
by applicable laws, by other appropriately licensed | ||||||
16 | personnel under the
supervision of or in
collaboration with a | ||||||
17 | physician licensed to practice medicine in all its
branches to | ||||||
18 | determine whether
the need for emergency services exists.
| ||||||
19 | "Emergency services" means, with respect to an enrollee of | ||||||
20 | a health care
plan,
transportation services, including but not | ||||||
21 | limited to ambulance services, and
covered inpatient and | ||||||
22 | outpatient hospital services
furnished by a provider
qualified | ||||||
23 | to furnish those services that are needed to evaluate or | ||||||
24 | stabilize an
emergency medical condition. "Emergency services" | ||||||
25 | does not
refer to post-stabilization medical services.
| ||||||
26 | "Enrollee" means any person and his or her dependents |
| |||||||
| |||||||
1 | enrolled in or covered
by a health care plan.
| ||||||
2 | "Health benefit plan" has the same meaning given that term | ||||||
3 | in the Health Carrier Grievance Procedure Law. | ||||||
4 | "Health care plan" means a plan that establishes, operates, | ||||||
5 | or maintains a
network of health care providers that has | ||||||
6 | entered into an agreement with the
plan to provide health care | ||||||
7 | services to enrollees to whom the plan has the
ultimate | ||||||
8 | obligation to arrange for the provision of or payment for | ||||||
9 | services
through organizational arrangements for ongoing | ||||||
10 | quality assurance,
utilization review programs, or dispute | ||||||
11 | resolution.
Nothing in this definition shall be construed to | ||||||
12 | mean that an independent
practice association or a physician | ||||||
13 | hospital organization that subcontracts
with
a health care plan | ||||||
14 | is, for purposes of that subcontract, a health care plan.
| ||||||
15 | For purposes of this definition, "health care plan" shall | ||||||
16 | not include the
following:
| ||||||
17 | (1) indemnity health insurance policies including | ||||||
18 | those using a contracted
provider network;
| ||||||
19 | (2) health care plans that offer only dental or only | ||||||
20 | vision coverage;
| ||||||
21 | (3) preferred provider administrators, as defined in | ||||||
22 | Section 370g(g) of
the
Illinois Insurance Code;
| ||||||
23 | (4) employee or employer self-insured health benefit | ||||||
24 | plans under the
federal Employee Retirement Income | ||||||
25 | Security Act of 1974;
| ||||||
26 | (5) health care provided pursuant to the Workers' |
| |||||||
| |||||||
1 | Compensation Act or the
Workers' Occupational Diseases | ||||||
2 | Act; and
| ||||||
3 | (6) not-for-profit voluntary health services plans | ||||||
4 | with health maintenance
organization
authority in | ||||||
5 | existence as of January 1, 1999 that are affiliated with a | ||||||
6 | union
and that
only extend coverage to union members and | ||||||
7 | their dependents.
| ||||||
8 | "Health care professional" means a physician, a registered | ||||||
9 | professional
nurse,
or other individual appropriately licensed | ||||||
10 | or registered
to provide health care services.
| ||||||
11 | "Health care provider" means any physician, hospital | ||||||
12 | facility, or other
person that is licensed or otherwise | ||||||
13 | authorized to deliver health care
services. Nothing in this
Act | ||||||
14 | shall be construed to define Independent Practice Associations | ||||||
15 | or
Physician-Hospital Organizations as health care providers.
| ||||||
16 | "Health care services" means any services included in the | ||||||
17 | furnishing to any
individual of medical care, or the
| ||||||
18 | hospitalization incident to the furnishing of such care, as | ||||||
19 | well as the
furnishing to any person of
any and all other | ||||||
20 | services for the purpose of preventing,
alleviating, curing, or | ||||||
21 | healing human illness or injury including home health
and | ||||||
22 | pharmaceutical services and products.
| ||||||
23 | "Health carrier" has the same meaning given that term in | ||||||
24 | the Health Carrier Grievance Procedure Law. | ||||||
25 | "Medical director" means a physician licensed in any state | ||||||
26 | to practice
medicine in all its
branches appointed by a health |
| |||||||
| |||||||
1 | care plan.
| ||||||
2 | "Person" means a corporation, association, partnership,
| ||||||
3 | limited liability company, sole proprietorship, or any other | ||||||
4 | legal entity.
| ||||||
5 | "Physician" means a person licensed under the Medical
| ||||||
6 | Practice Act of 1987.
| ||||||
7 | "Post-stabilization medical services" means health care | ||||||
8 | services
provided to an enrollee that are furnished in a | ||||||
9 | licensed hospital by a provider
that is qualified to furnish | ||||||
10 | such services, and determined to be medically
necessary and | ||||||
11 | directly related to the emergency medical condition following
| ||||||
12 | stabilization.
| ||||||
13 | "Prospective review" has the same meaning given that term | ||||||
14 | in the Health Carrier Grievance Procedure Law. | ||||||
15 | "Rescission" has the same meaning given that term in the | ||||||
16 | Health Carrier Grievance Procedure Law. | ||||||
17 | "Retrospective review" has the same meaning given that term | ||||||
18 | in the Health Carrier Grievance Procedure Law. | ||||||
19 | "Stabilization" means, with respect to an emergency | ||||||
20 | medical condition, to
provide such medical treatment of the | ||||||
21 | condition as may be necessary to assure,
within reasonable | ||||||
22 | medical probability, that no material deterioration
of the | ||||||
23 | condition is likely to result.
| ||||||
24 | "Utilization review" means a set of formal techniques | ||||||
25 | designed to monitor the use of, or evaluate the evaluation of | ||||||
26 | the medical necessity,
appropriateness, efficacy, or and |
| |||||||
| |||||||
1 | efficiency of , the use of health care services, procedures, | ||||||
2 | settings or
and facilities.
| ||||||
3 | "Utilization review program" means a program established | ||||||
4 | by a person to
perform utilization review.
| ||||||
5 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
6 | (215 ILCS 134/45)
| ||||||
7 | Sec. 45. Appeals of external Health care services appeals,
| ||||||
8 | complaints, and
external independent reviews. | ||||||
9 | (a) (Blank). A health care plan shall establish and | ||||||
10 | maintain an appeals procedure as
outlined in this Act. | ||||||
11 | Compliance with this Act's appeals procedures shall
satisfy a | ||||||
12 | health care plan's obligation to provide appeal procedures | ||||||
13 | under any
other State law or rules.
All appeals of a health | ||||||
14 | care plan's administrative determinations and
complaints | ||||||
15 | regarding its administrative decisions shall be handled as | ||||||
16 | required
under Section 50.
| ||||||
17 | (b) (Blank). When an appeal concerns a decision or action | ||||||
18 | by a health care plan,
its
employees, or its subcontractors | ||||||
19 | that relates to (i) health care services,
including, but not | ||||||
20 | limited to, procedures or
treatments,
for an enrollee with an | ||||||
21 | ongoing course of treatment ordered
by a health care provider,
| ||||||
22 | the denial of which could significantly
increase the risk to an
| ||||||
23 | enrollee's health,
or (ii) a treatment referral, service,
| ||||||
24 | procedure, or other health care service,
the denial of which | ||||||
25 | could significantly
increase the risk to an
enrollee's health,
|
| |||||||
| |||||||
1 | the health care plan must allow for the filing of an appeal
| ||||||
2 | either orally or in writing. Upon submission of the appeal, a | ||||||
3 | health care plan
must notify the party filing the appeal, as | ||||||
4 | soon as possible, but in no event
more than 24 hours after the | ||||||
5 | submission of the appeal, of all information
that the plan | ||||||
6 | requires to evaluate the appeal.
The health care plan shall | ||||||
7 | render a decision on the appeal within
24 hours after receipt | ||||||
8 | of the required information. The health care plan shall
notify | ||||||
9 | the party filing the
appeal and the enrollee, enrollee's | ||||||
10 | primary care physician, and any health care
provider who | ||||||
11 | recommended the health care service involved in the appeal of | ||||||
12 | its
decision orally
followed-up by a written notice of the | ||||||
13 | determination.
| ||||||
14 | (c) (Blank). For all appeals related to health care | ||||||
15 | services including, but not
limited to, procedures or | ||||||
16 | treatments for an enrollee and not covered by
subsection (b) | ||||||
17 | above, the health care
plan shall establish a procedure for the | ||||||
18 | filing of such appeals. Upon
submission of an appeal under this | ||||||
19 | subsection, a health care plan must notify
the party filing an | ||||||
20 | appeal, within 3 business days, of all information that the
| ||||||
21 | plan requires to evaluate the appeal.
The health care plan | ||||||
22 | shall render a decision on the appeal within 15 business
days | ||||||
23 | after receipt of the required information. The health care plan | ||||||
24 | shall
notify the party filing the appeal,
the enrollee, the | ||||||
25 | enrollee's primary care physician, and any health care
provider
| ||||||
26 | who recommended the health care service involved in the appeal |
| |||||||
| |||||||
1 | orally of its
decision followed-up by a written notice of the | ||||||
2 | determination.
| ||||||
3 | (d) (Blank). An appeal under subsection (b) or (c) may be | ||||||
4 | filed by the
enrollee, the enrollee's designee or guardian, the | ||||||
5 | enrollee's primary care
physician, or the enrollee's health | ||||||
6 | care provider. A health care plan shall
designate a clinical | ||||||
7 | peer to review
appeals, because these appeals pertain to | ||||||
8 | medical or clinical matters
and such an appeal must be reviewed | ||||||
9 | by an appropriate
health care professional. No one reviewing an | ||||||
10 | appeal may have had any
involvement
in the initial | ||||||
11 | determination that is the subject of the appeal. The written
| ||||||
12 | notice of determination required under subsections (b) and (c) | ||||||
13 | shall
include (i) clear and detailed reasons for the | ||||||
14 | determination, (ii)
the medical or
clinical criteria for the | ||||||
15 | determination, which shall be based upon sound
clinical | ||||||
16 | evidence and reviewed on a periodic basis, and (iii) in the | ||||||
17 | case of an
adverse determination, the
procedures for requesting | ||||||
18 | an external independent review as provided by the Illinois | ||||||
19 | Health Carrier External Review Act.
| ||||||
20 | (e) (Blank). If an appeal filed under subsection (b) or (c) | ||||||
21 | is denied for a reason
including, but not limited to, the
| ||||||
22 | service, procedure, or treatment is not viewed as medically | ||||||
23 | necessary,
denial of specific tests or procedures, denial of | ||||||
24 | referral
to specialist physicians or denial of hospitalization | ||||||
25 | requests or length of
stay requests, any involved party may | ||||||
26 | request an external independent review as provided by the |
| |||||||
| |||||||
1 | Illinois Health Carrier External Review Act.
| ||||||
2 | (f) Until July 1, 2013, if an external independent review | ||||||
3 | decision made pursuant to the Illinois Health Carrier External | ||||||
4 | Review Act upholds a determination adverse to the covered | ||||||
5 | person, the covered person has the right to appeal the final | ||||||
6 | decision to the Department; if the external review decision is | ||||||
7 | found by the Director to have been arbitrary and capricious, | ||||||
8 | then the Director, with consultation from a licensed medical | ||||||
9 | professional, may overturn the external review decision and | ||||||
10 | require the health carrier to pay for the health care service
| ||||||
11 | or treatment; such decision, if any, shall be made solely on
| ||||||
12 | the legal or medical merits of the claim. If an external review | ||||||
13 | decision is overturned by the Director pursuant to this Section | ||||||
14 | and the health carrier so requests, then the Director shall | ||||||
15 | assign a new independent review organization to reconsider the | ||||||
16 | overturned decision. The new independent review organization | ||||||
17 | shall follow subsection (d) of Section 40 of the Health Carrier | ||||||
18 | External Review Act in rendering a decision.
| ||||||
19 | (g) Future contractual or employment action by the health | ||||||
20 | care plan
regarding the
patient's physician or other health | ||||||
21 | care provider shall not be based solely on
the physician's or | ||||||
22 | other
health care provider's participation in health care | ||||||
23 | services appeals,
complaints, or
external independent reviews | ||||||
24 | under the Illinois Health Carrier External Review Act.
| ||||||
25 | (h) Nothing in this Section shall be construed to require a | ||||||
26 | health care
plan to pay for a health care service not covered |
| |||||||
| |||||||
1 | under the terms of the enrollee's
certificate of coverage or | ||||||
2 | policy , unless the terms are inconsistent with applicable law .
| ||||||
3 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
4 | (215 ILCS 134/85)
| ||||||
5 | Sec. 85. Utilization review program registration.
| ||||||
6 | (a) No person may conduct a utilization review program in | ||||||
7 | this State unless
once every 2 years the person
registers the | ||||||
8 | utilization review program with the Department and certifies
| ||||||
9 | compliance with the Health
Utilization Management Standards of | ||||||
10 | the American Accreditation Healthcare
Commission (URAC) | ||||||
11 | sufficient to achieve American Accreditation Healthcare
| ||||||
12 | Commission (URAC) accreditation or submits evidence of | ||||||
13 | accreditation by the
American
Accreditation Healthcare | ||||||
14 | Commission (URAC) for its Health Utilization
Management | ||||||
15 | Standards.
Nothing in this Act shall be construed to require a | ||||||
16 | health carrier care plan or its
subcontractors to become | ||||||
17 | American Accreditation Healthcare Commission (URAC)
| ||||||
18 | accredited.
| ||||||
19 | (b) In addition, the Director of the Department, in | ||||||
20 | consultation with the
Director of the Department of Public | ||||||
21 | Health, may certify alternative
utilization review standards | ||||||
22 | of national accreditation organizations or
entities in order | ||||||
23 | for plans to comply with this Section. Any alternative
| ||||||
24 | utilization review standards shall meet or exceed those | ||||||
25 | standards required
under subsection (a).
|
| |||||||
| |||||||
1 | (c) The provisions of this Section do not apply to:
| ||||||
2 | (1) persons providing utilization review program | ||||||
3 | services only to the
federal
government;
| ||||||
4 | (2) self-insured health plans under the federal | ||||||
5 | Employee Retirement Income
Security Act of 1974, however, | ||||||
6 | this Section does apply to persons conducting
a utilization | ||||||
7 | review program on behalf of these health plans;
| ||||||
8 | (3) hospitals and medical groups performing | ||||||
9 | utilization review activities
for
internal purposes unless | ||||||
10 | the utilization review program is conducted for
another | ||||||
11 | person.
| ||||||
12 | Nothing in this Act prohibits a health care plan or other | ||||||
13 | entity from
contractually requiring an entity designated in | ||||||
14 | item (3) of this subsection
to adhere to
the
utilization review | ||||||
15 | program requirements of
this Act.
| ||||||
16 | (d) This registration shall include submission of all of | ||||||
17 | the following
information
regarding utilization review program | ||||||
18 | activities:
| ||||||
19 | (1) The name, address, and telephone number of the | ||||||
20 | utilization review
programs.
| ||||||
21 | (2) The organization and governing structure of the | ||||||
22 | utilization review
programs.
| ||||||
23 | (3) The
number of lives for which utilization review is | ||||||
24 | conducted by each utilization
review program.
| ||||||
25 | (4) Hours of operation of each utilization review | ||||||
26 | program.
|
| |||||||
| |||||||
1 | (5) Description of the grievance process for each | ||||||
2 | utilization review
program.
| ||||||
3 | (6) Number of covered lives for which utilization | ||||||
4 | review was conducted for
the previous calendar year for | ||||||
5 | each utilization review program.
| ||||||
6 | (7) Written policies and procedures for protecting | ||||||
7 | confidential
information
according to applicable State and | ||||||
8 | federal laws for each utilization review
program.
| ||||||
9 | (e) (1) A utilization review program shall have written | ||||||
10 | procedures for
assuring that patient-specific information | ||||||
11 | obtained during the process of
utilization review will be:
| ||||||
12 | (A) kept confidential in accordance with applicable | ||||||
13 | State and
federal laws; and
| ||||||
14 | (B) shared only with the enrollee, the enrollee's | ||||||
15 | designee, the
enrollee's health
care provider, and those | ||||||
16 | who are authorized by law to receive the information.
| ||||||
17 | Summary data shall not be considered confidential if it | ||||||
18 | does not provide
information to allow identification of | ||||||
19 | individual patients or health care
providers.
| ||||||
20 | (2) Only a health care professional may make | ||||||
21 | determinations regarding
the medical
necessity of health | ||||||
22 | care services during the course of utilization review.
| ||||||
23 | (3) When making retrospective reviews, utilization | ||||||
24 | review programs shall
base
reviews solely on the medical | ||||||
25 | information available to the attending physician
or | ||||||
26 | ordering provider at the time the health care services were |
| |||||||
| |||||||
1 | provided.
| ||||||
2 | (4) When making prospective, concurrent, and | ||||||
3 | retrospective determinations,
utilization review programs | ||||||
4 | shall collect only information that is necessary to
make | ||||||
5 | the determination and shall not routinely require health | ||||||
6 | care providers to
numerically code diagnoses or procedures | ||||||
7 | to be considered for certification,
unless required under | ||||||
8 | State or federal Medicare or Medicaid rules or
regulations, | ||||||
9 | but may request such code if available, or routinely | ||||||
10 | request
copies
of medical records of all enrollees
| ||||||
11 | reviewed. During prospective or concurrent review, copies | ||||||
12 | of medical records
shall only be required when necessary to | ||||||
13 | verify that the health care services
subject to review are | ||||||
14 | medically necessary. In these cases, only the necessary
or
| ||||||
15 | relevant sections of the medical record shall be required.
| ||||||
16 | (f) If the Department finds that a utilization review | ||||||
17 | program is
not in compliance with this Section, the Department | ||||||
18 | shall issue a corrective
action plan and allow a reasonable | ||||||
19 | amount of time for compliance with the plan.
If the utilization | ||||||
20 | review program does not come into compliance, the
Department | ||||||
21 | may issue a cease and desist order. Before issuing a cease and
| ||||||
22 | desist order under this Section, the Department shall provide | ||||||
23 | the
utilization review program with a written notice of the | ||||||
24 | reasons for the
order and allow a reasonable amount of time to | ||||||
25 | supply additional information
demonstrating compliance with | ||||||
26 | requirements of this Section and to request a
hearing. The |
| |||||||
| |||||||
1 | hearing notice shall be sent by certified mail, return receipt
| ||||||
2 | requested, and the hearing shall be conducted in accordance | ||||||
3 | with the Illinois
Administrative Procedure Act.
| ||||||
4 | (g) A utilization review program subject to a corrective | ||||||
5 | action may continue
to conduct business
until a final decision | ||||||
6 | has been issued by the Department.
| ||||||
7 | (h) Any adverse determination made by a health carrier care | ||||||
8 | plan or its
subcontractors may be appealed
in accordance with | ||||||
9 | the Health Carrier Grievance Procedure Law subsection (f) of | ||||||
10 | Section 45 .
| ||||||
11 | (i) The Director may by rule establish a registration fee | ||||||
12 | for each person
conducting a utilization review program. All | ||||||
13 | fees paid to and collected by the
Director under this Section | ||||||
14 | shall be deposited into
the Insurance Producer Administration | ||||||
15 | Fund.
| ||||||
16 | (Source: P.A. 91-617, eff. 7-1-00.)
| ||||||
17 | Section 90-10. The Health Carrier External Review Act is | ||||||
18 | amended by changing Sections 10, 20, 25, 30, 35, 40, 55, 65, | ||||||
19 | and 75 and by adding Sections 42 and 80 as follows:
| ||||||
20 | (215 ILCS 180/10)
| ||||||
21 | Sec. 10. Definitions. For the purposes of this Act: | ||||||
22 | "Adverse determination" has the same meaning given that | ||||||
23 | term in the Health Carrier Grievance Procedure Law means a | ||||||
24 | determination by a health carrier or its designee utilization |
| |||||||
| |||||||
1 | review organization that an admission, availability of care, | ||||||
2 | continued stay, or other health care service that is a covered | ||||||
3 | benefit has been reviewed and, based upon the information | ||||||
4 | provided, does not meet the health carrier's requirements for | ||||||
5 | medical necessity, appropriateness, health care setting, level | ||||||
6 | of care, or effectiveness, and the requested service or payment | ||||||
7 | for the service is therefore denied, reduced, or terminated . | ||||||
8 | "Authorized representative" has the same meaning given | ||||||
9 | that term in the Health Carrier Grievance Procedure Law. means: | ||||||
10 | (1) a person to whom a covered person has given express | ||||||
11 | written consent to represent the covered person in an | ||||||
12 | external review, including the covered person's health | ||||||
13 | care provider; | ||||||
14 | (2) a person authorized by law to provide substituted | ||||||
15 | consent for a covered person; or | ||||||
16 | (3) the covered person's health care provider when the | ||||||
17 | covered person is unable to provide consent. | ||||||
18 | "Best evidence" means evidence based on: | ||||||
19 | (1) randomized clinical trials; | ||||||
20 | (2) if randomized clinical trials are not available, | ||||||
21 | then cohort studies or case-control studies; | ||||||
22 | (3) if items (1) and (2) are not available, then | ||||||
23 | case-series; or | ||||||
24 | (4) if items (1), (2), and (3) are not available, then | ||||||
25 | expert opinion. | ||||||
26 | "Case-series" means an evaluation of a series of patients |
| |||||||
| |||||||
1 | with a particular outcome, without the use of a control group. | ||||||
2 | "Clinical review criteria" has the same meaning given that | ||||||
3 | term in the Health Carrier Grievance Procedure Law means the | ||||||
4 | written screening procedures, decision abstracts, clinical | ||||||
5 | protocols, and practice guidelines used by a health carrier to | ||||||
6 | determine the necessity and appropriateness of health care | ||||||
7 | services . | ||||||
8 | "Cohort study" means a prospective evaluation of 2 groups | ||||||
9 | of patients with only one group of patients receiving specific | ||||||
10 | intervention. | ||||||
11 | "Covered benefits" or "benefits" has the same meaning given | ||||||
12 | that term in the Health Carrier Grievance Procedure Law means | ||||||
13 | those health care services to which a covered person is | ||||||
14 | entitled under the terms of a health benefit plan . | ||||||
15 | "Covered person" has the same meaning given that term in | ||||||
16 | the Health Carrier Grievance Procedure Law means a | ||||||
17 | policyholder, subscriber, enrollee, or other individual | ||||||
18 | participating in a health benefit plan . | ||||||
19 | "Director" means the Director of the Department of | ||||||
20 | Insurance. | ||||||
21 | "Emergency medical condition" has the same meaning given | ||||||
22 | that term in the Health Carrier Grievance Procedure Law. means | ||||||
23 | a medical condition manifesting itself by acute symptoms of | ||||||
24 | sufficient severity, including, but not limited to, severe | ||||||
25 | pain, such that a prudent layperson who possesses an average | ||||||
26 | knowledge of health and medicine could reasonably expect the |
| |||||||
| |||||||
1 | absence of immediate medical attention to result in: | ||||||
2 | (1) placing the health of the individual or, with | ||||||
3 | respect to a pregnant woman, the health of the woman or her | ||||||
4 | unborn child, in serious jeopardy; | ||||||
5 | (2) serious impairment to bodily functions; or
| ||||||
6 | (3) serious dysfunction of any bodily organ or part. | ||||||
7 | "Emergency services" has the same meaning given that term | ||||||
8 | in the Health Carrier Grievance Procedure Law means health care | ||||||
9 | items and services furnished or required to evaluate and treat | ||||||
10 | an emergency medical condition . | ||||||
11 | "Evidence-based standard" means the conscientious, | ||||||
12 | explicit, and judicious use of the current best evidence based | ||||||
13 | on an overall systematic review of the research in making | ||||||
14 | decisions about the care of individual patients. | ||||||
15 | "Expert opinion" means a belief or an interpretation by | ||||||
16 | specialists with experience in a specific area about the | ||||||
17 | scientific evidence pertaining to a particular service, | ||||||
18 | intervention, or therapy. | ||||||
19 | "Facility" has the same meaning given that term in the | ||||||
20 | Health Carrier Grievance Procedure Law means an institution | ||||||
21 | providing health care services or a health care setting . | ||||||
22 | "Final adverse determination" has the same meaning given | ||||||
23 | that term in the Health Carrier Grievance Procedure Law means | ||||||
24 | an adverse determination involving a covered benefit that has | ||||||
25 | been upheld by a health carrier, or its designee utilization | ||||||
26 | review organization, at the completion of the health carrier's |
| |||||||
| |||||||
1 | internal grievance process procedures as set forth by the | ||||||
2 | Managed Care Reform and Patient Rights Act . | ||||||
3 | "Health benefit plan" has the same meaning given that term | ||||||
4 | in the Health Carrier Grievance Procedure Law means a policy, | ||||||
5 | contract, certificate, plan, or agreement offered or issued by | ||||||
6 | a health carrier to provide, deliver, arrange for, pay for, or | ||||||
7 | reimburse any of the costs of health care services . | ||||||
8 | "Health care professional" has the same meaning given that | ||||||
9 | term in the Health Carrier Grievance Procedure Law. | ||||||
10 | "Health care provider" or "provider" has the same meaning | ||||||
11 | given that term in the Health Carrier Grievance Procedure Law | ||||||
12 | means a physician, hospital facility, or other health care | ||||||
13 | practitioner licensed, accredited, or certified to perform | ||||||
14 | specified health care services consistent with State law, | ||||||
15 | responsible for recommending health care services on behalf of | ||||||
16 | a covered person . | ||||||
17 | "Health care services" has the same meaning given that term | ||||||
18 | in the Health Carrier Grievance Procedure Law means services | ||||||
19 | for the diagnosis, prevention, treatment, cure, or relief of a | ||||||
20 | health condition, illness, injury, or disease . | ||||||
21 | "Health carrier" has the same meaning given that term in | ||||||
22 | the Health Carrier Grievance Procedure Law means an entity | ||||||
23 | subject to the insurance laws and regulations of this State, or | ||||||
24 | subject to the jurisdiction of the Director, that contracts or | ||||||
25 | offers to contract to provide, deliver, arrange for, pay for, | ||||||
26 | or reimburse any of the costs of health care services, |
| |||||||
| |||||||
1 | including a sickness and accident insurance company, a health | ||||||
2 | maintenance organization, or any other entity providing a plan | ||||||
3 | of health insurance, health benefits, or health care services. | ||||||
4 | "Health carrier" also means Limited Health Service | ||||||
5 | Organizations (LHSO) and Voluntary Health Service Plans . | ||||||
6 | "Health information" means information or data, whether | ||||||
7 | oral or recorded in any form or medium, and personal facts or | ||||||
8 | information about events or relationships that relate to:
| ||||||
9 | (1) the past, present, or future physical, mental, or | ||||||
10 | behavioral health or condition of an individual or a member | ||||||
11 | of the individual's family; | ||||||
12 | (2) the provision of health care services to an | ||||||
13 | individual; or | ||||||
14 | (3) payment for the provision of health care services | ||||||
15 | to an individual. | ||||||
16 | "Independent review organization" means an entity that | ||||||
17 | conducts independent external reviews of adverse | ||||||
18 | determinations and final adverse determinations. | ||||||
19 | "Medical or scientific evidence" means evidence found in | ||||||
20 | the following sources: | ||||||
21 | (1) peer-reviewed scientific studies published in or | ||||||
22 | accepted for publication by medical journals that meet | ||||||
23 | nationally recognized requirements for scientific | ||||||
24 | manuscripts and that submit most of their published | ||||||
25 | articles for review by experts who are not part of the | ||||||
26 | editorial staff; |
| |||||||
| |||||||
1 | (2) peer-reviewed medical literature, including | ||||||
2 | literature relating to therapies reviewed and approved by a | ||||||
3 | qualified institutional review board, biomedical | ||||||
4 | compendia, and other medical literature that meet the | ||||||
5 | criteria of the National Institutes of Health's Library of | ||||||
6 | Medicine for indexing in Index Medicus (Medline) and | ||||||
7 | Elsevier Science Ltd. for indexing in Excerpta Medicus | ||||||
8 | (EMBASE); | ||||||
9 | (3) medical journals recognized by the Secretary of | ||||||
10 | Health and Human Services under Section 1861(t)(2) of the | ||||||
11 | federal Social Security Act; | ||||||
12 | (4) the following standard reference compendia:
| ||||||
13 | (a) The American Hospital Formulary Service-Drug | ||||||
14 | Information; | ||||||
15 | (b) Drug Facts and Comparisons; | ||||||
16 | (c) The American Dental Association Accepted | ||||||
17 | Dental Therapeutics; and | ||||||
18 | (d) The United States Pharmacopoeia-Drug | ||||||
19 | Information; | ||||||
20 | (5) findings, studies, or research conducted by or | ||||||
21 | under the auspices of federal government agencies and | ||||||
22 | nationally recognized federal research institutes, | ||||||
23 | including: | ||||||
24 | (a) the federal Agency for Healthcare Research and | ||||||
25 | Quality; | ||||||
26 | (b) the National Institutes of Health; |
| |||||||
| |||||||
1 | (c) the National Cancer Institute; | ||||||
2 | (d) the National Academy of Sciences; | ||||||
3 | (e) the Centers for Medicare & Medicaid Services; | ||||||
4 | (f) the federal Food and Drug Administration; and | ||||||
5 | (g) any national board recognized by the National | ||||||
6 | Institutes of Health for the purpose of evaluating the | ||||||
7 | medical value of health care services; or | ||||||
8 | (6) any other medical or scientific evidence that is | ||||||
9 | comparable to the sources listed in items (1) through (5). | ||||||
10 | "Person" has the same meaning given that term in the Health | ||||||
11 | Carrier Grievance Procedure Law. | ||||||
12 | "Protected health information" means health information | ||||||
13 | (i) that identifies an individual who is the subject of the | ||||||
14 | information; or (ii) with respect to which there is a | ||||||
15 | reasonable basis to believe that the information could be used | ||||||
16 | to identify an individual. | ||||||
17 | "Randomized clinical trial" means a controlled prospective | ||||||
18 | study of patients that have been randomized into an | ||||||
19 | experimental group and a control group at the beginning of the | ||||||
20 | study with only the experimental group of patients receiving a | ||||||
21 | specific intervention, which includes study of the groups for | ||||||
22 | variables and anticipated outcomes over time. | ||||||
23 | "Retrospective review" has the same meaning given that term | ||||||
24 | in the Health Carrier Grievance Procedure Law means a review of | ||||||
25 | medical necessity conducted after services have been provided | ||||||
26 | to a patient, but does not include the review of a claim that |
| |||||||
| |||||||
1 | is limited to an evaluation of reimbursement levels, veracity | ||||||
2 | of documentation, accuracy of coding, or adjudication for | ||||||
3 | payment . | ||||||
4 | "Utilization review" has the meaning provided by the | ||||||
5 | Managed Care Reform and Patient Rights Act. | ||||||
6 | "Utilization review organization" means a utilization | ||||||
7 | review program as defined in the Managed Care Reform and | ||||||
8 | Patient Rights Act.
| ||||||
9 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
10 | (215 ILCS 180/20)
| ||||||
11 | Sec. 20. Notice of right to external review. | ||||||
12 | (a) At the same time the health carrier sends written | ||||||
13 | notice of a covered person's right to appeal a coverage | ||||||
14 | decision upon an adverse determination or a final adverse | ||||||
15 | determination as provided by the Managed Care Reform and | ||||||
16 | Patient Rights Act , a health carrier shall notify a covered | ||||||
17 | person , the covered person's authorized representative, if | ||||||
18 | any, and a covered person's health care provider in writing of | ||||||
19 | the covered person's right to request an external review as | ||||||
20 | provided by this Act. The written notice required shall include | ||||||
21 | the following, or substantially equivalent, language: "We have | ||||||
22 | denied your request for the provision of or payment for a | ||||||
23 | health care service or course of treatment. You have the right | ||||||
24 | to have our decision reviewed by an independent review | ||||||
25 | organization not associated with us if our decision involved |
| |||||||
| |||||||
1 | making a judgment as to the medical necessity, appropriateness, | ||||||
2 | health care setting, level of care, or effectiveness of the | ||||||
3 | health care service or treatment you requested by submitting a | ||||||
4 | written request for an external review to the Department of | ||||||
5 | Insurance, Office of Consumer Health Information, 320 West | ||||||
6 | Washington Street, 4th Floor, Springfield, Illinois, 62767." | ||||||
7 | us . Upon receipt of your request an independent review | ||||||
8 | organization registered with the Department of Insurance will | ||||||
9 | be assigned to review our decision. | ||||||
10 | (a-5) The Department may prescribe the form and content of | ||||||
11 | the notice required under this Section. | ||||||
12 | (b) This subsection (b) shall apply to an expedited review | ||||||
13 | prior to a final adverse determination. In addition to the | ||||||
14 | notice required in subsection (a), for the health carrier shall | ||||||
15 | include a notice related to an adverse determination, the | ||||||
16 | health carrier shall include a statement informing the covered | ||||||
17 | person of all of the following: | ||||||
18 | (1) If the covered person has a medical condition where | ||||||
19 | the timeframe for completion of (A) an expedited internal | ||||||
20 | review of an appeal a grievance involving an adverse | ||||||
21 | determination, (B) a final adverse determination as set | ||||||
22 | forth in the Managed Care Reform and Patient Rights Act , or | ||||||
23 | (C) a standard external review as established in this Act, | ||||||
24 | would seriously jeopardize the life or health of the | ||||||
25 | covered person or would jeopardize the covered person's | ||||||
26 | ability to regain maximum function, then the covered person |
| |||||||
| |||||||
1 | or the covered person's authorized representative may file | ||||||
2 | a request for an expedited external review. | ||||||
3 | (2) The covered person or the covered person's | ||||||
4 | authorized representative may file an appeal under the | ||||||
5 | health carrier's internal appeal process as set forth in | ||||||
6 | the Health Carrier Grievance Procedure Law, but if the | ||||||
7 | health carrier has not issued a written decision to the | ||||||
8 | covered person or the covered person's authorized | ||||||
9 | representative 30 days following the date the covered | ||||||
10 | person or the covered person's authorized representative | ||||||
11 | files an appeal of an adverse determination that involves a | ||||||
12 | prospective review request or 60 days following the date | ||||||
13 | the covered person or the covered person's authorized | ||||||
14 | representative files an appeal of an adverse determination | ||||||
15 | that involves a retrospective review request with the | ||||||
16 | health carrier and the covered person or the covered | ||||||
17 | person's authorized representative has not requested or | ||||||
18 | agreed to a delay, then the covered person or the covered | ||||||
19 | person's authorized representative may file a request for | ||||||
20 | external review and shall be considered to have exhausted | ||||||
21 | the health carrier's internal appeal process for purposes | ||||||
22 | of this Act. The covered person or the covered person's | ||||||
23 | authorized representative may file a request for an | ||||||
24 | expedited external review at the same time the covered | ||||||
25 | person or the covered person's authorized representative | ||||||
26 | files a request for an expedited internal appeal involving |
| |||||||
| |||||||
1 | an adverse determination as set forth in the Managed Care | ||||||
2 | Reform and Patient Rights Act if the adverse determination | ||||||
3 | involves a denial of coverage based on a determination that | ||||||
4 | the recommended or requested health care service or | ||||||
5 | treatment is experimental or investigational and the | ||||||
6 | covered person's health care provider certifies in writing | ||||||
7 | that the recommended or requested health care service or | ||||||
8 | treatment that is the subject of the adverse determination | ||||||
9 | would be significantly less effective if not promptly | ||||||
10 | initiated. The independent review organization assigned to | ||||||
11 | conduct the expedited external review will determine | ||||||
12 | whether the covered person shall be required to complete | ||||||
13 | the expedited review of the grievance prior to conducting | ||||||
14 | the expedited external review. | ||||||
15 | (3) The covered person or the covered person's | ||||||
16 | authorized representative filed a request for an expedited | ||||||
17 | internal review of an adverse determination pursuant to the | ||||||
18 | Health Carrier Grievance Procedure Law and has not received | ||||||
19 | a decision on such request from the health carrier within | ||||||
20 | 48 hours, except to the extent the covered person or the | ||||||
21 | covered person's authorized representative requested or | ||||||
22 | agreed to a delay. | ||||||
23 | (4) (3) If an adverse determination concerns a denial | ||||||
24 | of coverage based on a determination that the recommended | ||||||
25 | or requested health care service or treatment is | ||||||
26 | experimental or investigational and the covered person's |
| |||||||
| |||||||
1 | health care provider certifies in writing that the | ||||||
2 | recommended or requested health care service or treatment | ||||||
3 | that is the subject of the request would be significantly | ||||||
4 | less effective if not promptly initiated, then the covered | ||||||
5 | person or the covered person's authorized representative | ||||||
6 | may request an expedited external review at the same time | ||||||
7 | the covered person or the covered person's authorized | ||||||
8 | representative files a request for an expedited internal | ||||||
9 | appeal involving an adverse determination as set forth in | ||||||
10 | the Health Carrier Grievance Procedure Law. The | ||||||
11 | independent review organization assigned to conduct the | ||||||
12 | expedited external review shall determine whether the | ||||||
13 | covered person is required to complete the expedited review | ||||||
14 | of the appeal prior to conducting the expedited external | ||||||
15 | review . | ||||||
16 | (c) This subsection (c) shall apply to an expedited review | ||||||
17 | upon final adverse determination. In addition to the notice | ||||||
18 | required in subsection (a), for the health carrier shall | ||||||
19 | include a notice related to a final adverse determination, the | ||||||
20 | health carrier shall include a statement informing the covered | ||||||
21 | person of all of the following: | ||||||
22 | (1) if the covered person has a medical condition where | ||||||
23 | the timeframe for completion of a standard external review | ||||||
24 | would seriously jeopardize the life or health of the | ||||||
25 | covered person or would jeopardize the covered person's | ||||||
26 | ability to regain maximum function, then the covered person |
| |||||||
| |||||||
1 | or the covered person's authorized representative may file | ||||||
2 | a request for an expedited external review; or | ||||||
3 | (2) if a final adverse determination concerns an | ||||||
4 | admission, availability of care, continued stay, or health | ||||||
5 | care service for which the covered person received | ||||||
6 | emergency services, but has not been discharged from a | ||||||
7 | facility, then the covered person, or the covered person's | ||||||
8 | authorized representative, may request an expedited | ||||||
9 | external review; or | ||||||
10 | (3) if a final adverse determination concerns a denial | ||||||
11 | of coverage based on a determination that the recommended | ||||||
12 | or requested health care service or treatment is | ||||||
13 | experimental or investigational, and the covered person's | ||||||
14 | health care provider certifies in writing that the | ||||||
15 | recommended or requested health care service or treatment | ||||||
16 | that is the subject of the request would be significantly | ||||||
17 | less effective if not promptly initiated, then the covered | ||||||
18 | person or the covered person's authorized representative | ||||||
19 | may request an expedited external review. | ||||||
20 | (d) In addition to the information to be provided pursuant | ||||||
21 | to subsections (a), (b), and (c) of this Section, the health | ||||||
22 | carrier shall include a copy of the description of both the | ||||||
23 | required standard and expedited external review procedures. | ||||||
24 | The description shall highlight the external review procedures | ||||||
25 | that give the covered person or the covered person's authorized | ||||||
26 | representative the opportunity to submit additional |
| |||||||
| |||||||
1 | information, including any forms used to process an external | ||||||
2 | review.
| ||||||
3 | (e) As part of any forms provided under subsection (d) of | ||||||
4 | this Section, the health carrier shall include an authorization | ||||||
5 | form, or other document approved by the Director, by which the | ||||||
6 | covered person, for purposes of conducting an external review | ||||||
7 | under this Act, authorizes the health carrier and the covered | ||||||
8 | person's treating health care provider to disclose protected | ||||||
9 | health information, including medical records, concerning the | ||||||
10 | covered person that is pertinent to the external review, as | ||||||
11 | provided in the Illinois Insurance Code. | ||||||
12 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
13 | (215 ILCS 180/25)
| ||||||
14 | Sec. 25. Request for external review. A covered person or | ||||||
15 | the covered person's authorized representative may make a | ||||||
16 | request for a standard external or expedited external review of | ||||||
17 | an adverse determination or final adverse determination. | ||||||
18 | Except as set forth in Sections 40 and 42 of this Act, all | ||||||
19 | requests for external review Requests under this Section shall | ||||||
20 | be made in writing to the Director directly to the health | ||||||
21 | carrier that made the adverse or final adverse determination. | ||||||
22 | All requests for external review shall be in writing except for | ||||||
23 | requests for expedited external reviews which may me made | ||||||
24 | orally . Health carriers must provide covered persons with forms | ||||||
25 | to request external reviews.
|
| |||||||
| |||||||
1 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
2 | (215 ILCS 180/30)
| ||||||
3 | Sec. 30. Exhaustion of internal appeal grievance process. | ||||||
4 | (a) Except as provided in subsection (b) of this Section | ||||||
5 | 20 , a request for an external review shall not be made until | ||||||
6 | the covered person has exhausted the health carrier's internal | ||||||
7 | appeal grievance process as set forth in the Health Carrier | ||||||
8 | Grievance Procedure Law Managed Care Reform and Patient Rights | ||||||
9 | Act . | ||||||
10 | (b) A covered person shall also be considered to have | ||||||
11 | exhausted the health carrier's internal appeal grievance | ||||||
12 | process for purposes of this Section if: | ||||||
13 | (1) the covered person or the covered person's | ||||||
14 | authorized representative has filed an appeal under the | ||||||
15 | health carrier's internal appeal process as set forth in a | ||||||
16 | request for an internal review of an adverse determination | ||||||
17 | pursuant to the Health Carrier Grievance Procedure Law | ||||||
18 | Managed Care Reform and Patient Rights Act and has not | ||||||
19 | received a written decision on the appeal 30 days following | ||||||
20 | the date the covered person or the covered person's | ||||||
21 | authorized representative files an appeal of an adverse | ||||||
22 | determination that involves a prospective review request | ||||||
23 | or 60 days following the date the covered person or the | ||||||
24 | covered person's authorized representative files an appeal | ||||||
25 | of an adverse determination that involves a retrospective |
| |||||||
| |||||||
1 | review request request from the health carrier within 15 | ||||||
2 | days after receipt of the required information but not more | ||||||
3 | than 30 days after the request was filed by the covered | ||||||
4 | person or the covered person's authorized representative , | ||||||
5 | except to the extent the covered person or the covered | ||||||
6 | person's authorized representative requested or agreed to | ||||||
7 | a delay; however, a covered person or the covered person's | ||||||
8 | authorized representative may not make a request for an | ||||||
9 | external review of an adverse determination involving a | ||||||
10 | retrospective review determination until the covered | ||||||
11 | person has exhausted the health carrier's internal | ||||||
12 | grievance process; | ||||||
13 | (2) the covered person or the covered person's | ||||||
14 | authorized representative filed a request for an expedited | ||||||
15 | internal review of an adverse determination pursuant to the | ||||||
16 | Health Carrier Grievance Procedure Law Managed Care Reform | ||||||
17 | and Patient Rights Act and has not received a decision on | ||||||
18 | such request from the health carrier within 48 hours, | ||||||
19 | except to the extent the covered person or the covered | ||||||
20 | person's authorized representative requested or agreed to | ||||||
21 | a delay; or | ||||||
22 | (3) the health carrier agrees to waive the exhaustion | ||||||
23 | requirement ; .
| ||||||
24 | (4) the covered person has a medical condition in which | ||||||
25 | the timeframe for completion of (A) an expedited internal | ||||||
26 | review of a appeal involving an adverse determination, (B) |
| |||||||
| |||||||
1 | a final adverse determination, or (C) a standard external | ||||||
2 | review as established in this Act would seriously | ||||||
3 | jeopardize the life or health of the covered person or | ||||||
4 | would jeopardize the covered person's ability to regain | ||||||
5 | maximum function; | ||||||
6 | (5) an adverse determination concerns a denial of | ||||||
7 | coverage based on a determination that the recommended or | ||||||
8 | requested health care service or treatment is experimental | ||||||
9 | or investigational and the covered person's health care | ||||||
10 | provider certifies in writing that the recommended or | ||||||
11 | requested health care service or treatment that is the | ||||||
12 | subject of the request would be significantly less | ||||||
13 | effective if not promptly initiated; in such cases, the | ||||||
14 | covered person or the covered person's authorized | ||||||
15 | representative may request an expedited external review at | ||||||
16 | the same time the covered person or the covered person's | ||||||
17 | authorized representative files a request for an expedited | ||||||
18 | internal appeal involving an adverse determination as set | ||||||
19 | forth in the Health Carrier Grievance Procedure Law; the | ||||||
20 | independent review organization assigned to conduct the | ||||||
21 | expedited external review shall determine whether the | ||||||
22 | covered person is required to complete the expedited review | ||||||
23 | of the appeal prior to conducting the expedited external | ||||||
24 | review; or | ||||||
25 | (6) the health carrier has failed to comply with | ||||||
26 | Section 5-40 or 5-45 of the Utilization Review and Benefit |
| |||||||
| |||||||
1 | Determination Law, as set forth in subsection (d) of | ||||||
2 | Section 5-35 of that Law, or Section 10-30 or 10-40 of the | ||||||
3 | Health Carrier Grievance Procedure Law, as set forth in | ||||||
4 | subsection (b) of Section 10-25 of that Law. | ||||||
5 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
6 | (215 ILCS 180/35)
| ||||||
7 | Sec. 35. Standard external review. | ||||||
8 | (a) Within 4 months after the date of receipt of a notice | ||||||
9 | of an adverse determination or final adverse determination, a | ||||||
10 | covered person or the covered person's authorized | ||||||
11 | representative may file a request for an external review with | ||||||
12 | the Director. Within one business day after the date of receipt | ||||||
13 | of a request for external review, the Director shall send a | ||||||
14 | copy of the request to the health carrier. | ||||||
15 | (b) Within 5 business days following the date of receipt of | ||||||
16 | the external review request, the health carrier shall complete | ||||||
17 | a preliminary review of the request to determine whether:
| ||||||
18 | (1) the individual is or was a covered person in the | ||||||
19 | health benefit plan at the time the health care service was | ||||||
20 | requested or at the time the health care service was | ||||||
21 | provided; | ||||||
22 | (2) the health care service that is the subject of the | ||||||
23 | adverse determination or the final adverse determination | ||||||
24 | is a covered service under the covered person's health | ||||||
25 | benefit plan, but the health carrier has determined that |
| |||||||
| |||||||
1 | the health care service is not covered because it does not | ||||||
2 | meet the health carrier's requirements for medical | ||||||
3 | necessity, appropriateness, health care setting, level of | ||||||
4 | care, or effectiveness ; | ||||||
5 | (3) the covered person has exhausted the health | ||||||
6 | carrier's internal appeal grievance process as set forth in | ||||||
7 | the Health Carrier Grievance Procedure Act unless the | ||||||
8 | covered person is not required to exhaust the health | ||||||
9 | carrier's internal appeal process pursuant to this Act; | ||||||
10 | (4) (blank); and for appeals relating to a | ||||||
11 | determination based on treatment being experimental or | ||||||
12 | investigational, the requested health care service or | ||||||
13 | treatment that is the subject of the adverse determination | ||||||
14 | or final adverse determination is a covered benefit under | ||||||
15 | the covered person's health benefit plan except for the | ||||||
16 | health carrier's determination that the service or | ||||||
17 | treatment is experimental or investigational for a | ||||||
18 | particular medical condition and is not explicitly listed | ||||||
19 | as an excluded benefit under the covered person's health | ||||||
20 | benefit plan with the health carrier and that the covered | ||||||
21 | person's health care provider, who ordered or provided the | ||||||
22 | services in question and who is licensed under the
Medical | ||||||
23 | Practice Act of 1987, has certified that one of the | ||||||
24 | following situations is applicable: | ||||||
25 | (A) standard health care services or treatments | ||||||
26 | have not been effective in improving the condition of |
| |||||||
| |||||||
1 | the covered person; | ||||||
2 | (B) standard health care services or treatments | ||||||
3 | are not medically appropriate for the covered person; | ||||||
4 | (C) there is no available standard health care | ||||||
5 | service or treatment covered by the health carrier that | ||||||
6 | is more beneficial than the recommended or requested | ||||||
7 | health care service or treatment;
| ||||||
8 | (D) the health care service or treatment is likely | ||||||
9 | to be more beneficial to the covered person, in the | ||||||
10 | health care provider's opinion, than any available | ||||||
11 | standard health care services or treatments; or | ||||||
12 | (E) that scientifically valid studies using | ||||||
13 | accepted protocols demonstrate that the health care | ||||||
14 | service or treatment requested is likely to be more | ||||||
15 | beneficial to the covered person than any available | ||||||
16 | standard health care services or treatments; and | ||||||
17 | (5) the covered person has provided all the information | ||||||
18 | and forms required to process an external review, as | ||||||
19 | specified in this Act. | ||||||
20 | (c) Within one business day after completion of the | ||||||
21 | preliminary review, the health carrier shall notify the | ||||||
22 | Director and covered person and, if applicable, the covered | ||||||
23 | person's authorized representative in writing whether the | ||||||
24 | request is complete and eligible for external review. If the | ||||||
25 | request: | ||||||
26 | (1) is not complete, the health carrier shall inform |
| |||||||
| |||||||
1 | the Director and covered person and, if applicable, the | ||||||
2 | covered person's authorized representative in writing and | ||||||
3 | include in the notice what information or materials are | ||||||
4 | required by this Act to make the request complete; or | ||||||
5 | (2) is not eligible for external review, the health | ||||||
6 | carrier shall inform the Director and covered person and, | ||||||
7 | if applicable, the covered person's authorized | ||||||
8 | representative in writing and include in the notice the | ||||||
9 | reasons for its ineligibility.
| ||||||
10 | The Department may specify the form for the health | ||||||
11 | carrier's notice of initial determination under this | ||||||
12 | subsection (c) and any supporting information to be included in | ||||||
13 | the notice. | ||||||
14 | The notice of initial determination of ineligibility shall | ||||||
15 | include a statement informing the covered person and, if | ||||||
16 | applicable, the covered person's authorized representative | ||||||
17 | that a health carrier's initial determination that the external | ||||||
18 | review request is ineligible for review may be appealed to the | ||||||
19 | Director by filing a complaint with the Director. | ||||||
20 | Notwithstanding a health carrier's initial determination | ||||||
21 | that the request is ineligible for external review, the | ||||||
22 | Director may determine that a request is eligible for external | ||||||
23 | review and require that it be referred for external review. In | ||||||
24 | making such determination, the Director's decision shall be in | ||||||
25 | accordance with the terms of the covered person's health | ||||||
26 | benefit plan , unless such terms are inconsistent with |
| |||||||
| |||||||
1 | applicable law, and shall be subject to all applicable | ||||||
2 | provisions of this Act. | ||||||
3 | (d) Whenever the Director receives notice that a request is | ||||||
4 | eligible for external review following the preliminary review | ||||||
5 | conducted pursuant to this Section the health carrier shall , | ||||||
6 | within one 5 business day after the date of receipt of the | ||||||
7 | notice, the Director shall days : | ||||||
8 | (1) assign an independent review organization from the | ||||||
9 | list of approved independent review organizations compiled | ||||||
10 | and maintained by the Director pursuant to this Act and | ||||||
11 | notify the health carrier of the name of the assigned | ||||||
12 | independent review organization ; and | ||||||
13 | (2) notify in writing the covered person and, if | ||||||
14 | applicable, the covered person's authorized representative | ||||||
15 | of the request's eligibility and acceptance for external | ||||||
16 | review and the name of the independent review organization. | ||||||
17 | The Director health carrier shall include in the notice | ||||||
18 | provided to the covered person and, if applicable, the covered | ||||||
19 | person's authorized representative a statement that the | ||||||
20 | covered person or the covered person's authorized | ||||||
21 | representative may, within 5 business days following the date | ||||||
22 | of receipt of the notice provided pursuant to item (2) of this | ||||||
23 | subsection (d), submit in writing to the assigned independent | ||||||
24 | review organization additional information that the | ||||||
25 | independent review organization shall consider when conducting | ||||||
26 | the external review. The independent review organization is not |
| |||||||
| |||||||
1 | required to, but may, accept and consider additional | ||||||
2 | information submitted after 5 business days. | ||||||
3 | (e) The assignment by the Director of an approved | ||||||
4 | independent review organization to conduct an external review | ||||||
5 | in accordance with this Section shall be done on a random basis | ||||||
6 | among those independent review organizations approved by the | ||||||
7 | Director pursuant to this Act. The assignment of an approved | ||||||
8 | independent review organization to conduct an external review | ||||||
9 | in accordance with this Section shall be made from those | ||||||
10 | approved independent review organizations qualified to conduct | ||||||
11 | external review as required by Sections 50 and 55 of this Act. | ||||||
12 | (f) Within Upon assignment of an independent review | ||||||
13 | organization, the health carrier or its designee utilization | ||||||
14 | review organization shall, within 5 business days after the | ||||||
15 | date of receipt of the notice provided pursuant to item (1) of | ||||||
16 | subsection (d) of this Section , the health carrier or its | ||||||
17 | designee utilization review organization shall provide to the | ||||||
18 | assigned independent review organization the documents and any | ||||||
19 | information considered in making the adverse determination or | ||||||
20 | final adverse determination; in such cases, the following | ||||||
21 | provisions shall apply: | ||||||
22 | (1) Except as provided in item (2) of this subsection | ||||||
23 | (f), failure by the health carrier or its utilization | ||||||
24 | review organization to provide the documents and | ||||||
25 | information within the specified time frame shall not delay | ||||||
26 | the conduct of the external review. |
| |||||||
| |||||||
1 | (2) If the health carrier or its utilization review | ||||||
2 | organization fails to provide the documents and | ||||||
3 | information within the specified time frame, the assigned | ||||||
4 | independent review organization may terminate the external | ||||||
5 | review and make a decision to reverse the adverse | ||||||
6 | determination or final adverse determination. | ||||||
7 | (3) Within one business day after making the decision | ||||||
8 | to terminate the external review and make a decision to | ||||||
9 | reverse the adverse determination or final adverse | ||||||
10 | determination under item (2) of this subsection (f), the | ||||||
11 | independent review organization shall notify the Director, | ||||||
12 | the health carrier, the covered person and, if applicable, | ||||||
13 | the covered person's authorized representative, of its | ||||||
14 | decision to reverse the adverse determination. | ||||||
15 | (g) Upon receipt of the information from the health carrier | ||||||
16 | or its utilization review organization, the assigned | ||||||
17 | independent review organization shall review all of the | ||||||
18 | information and documents and any other information submitted | ||||||
19 | in writing to the independent review organization by the | ||||||
20 | covered person and the covered person's authorized | ||||||
21 | representative. | ||||||
22 | (h) Upon receipt of any information submitted by the | ||||||
23 | covered person or the covered person's authorized | ||||||
24 | representative, the independent review organization shall | ||||||
25 | forward the information to the health carrier within 1 business | ||||||
26 | day. |
| |||||||
| |||||||
1 | (1) Upon receipt of the information, if any, the health | ||||||
2 | carrier may reconsider its adverse determination or final | ||||||
3 | adverse determination that is the subject of the external | ||||||
4 | review.
| ||||||
5 | (2) Reconsideration by the health carrier of its | ||||||
6 | adverse determination or final adverse determination shall | ||||||
7 | not delay or terminate the external review.
| ||||||
8 | (3) The external review may only be terminated if the | ||||||
9 | health carrier decides, upon completion of its | ||||||
10 | reconsideration, to reverse its adverse determination or | ||||||
11 | final adverse determination and provide coverage or | ||||||
12 | payment for the health care service that is the subject of | ||||||
13 | the adverse determination or final adverse determination. | ||||||
14 | In such cases, the following provisions shall apply: | ||||||
15 | (A) Within one business day after making the | ||||||
16 | decision to reverse its adverse determination or final | ||||||
17 | adverse determination, the health carrier shall notify | ||||||
18 | the Director, the covered person and , if applicable, | ||||||
19 | the covered person's authorized representative, and | ||||||
20 | the assigned independent review organization in | ||||||
21 | writing of its decision. | ||||||
22 | (B) Upon notice from the health carrier that the | ||||||
23 | health carrier has made a decision to reverse its | ||||||
24 | adverse determination or final adverse determination, | ||||||
25 | the assigned independent review organization shall | ||||||
26 | terminate the external review. |
| |||||||
| |||||||
1 | (i) In addition to the documents and information provided | ||||||
2 | by the health carrier or its utilization review organization | ||||||
3 | and the covered person and the covered person's authorized | ||||||
4 | representative, if any, the independent review organization, | ||||||
5 | to the extent the information or documents are available and | ||||||
6 | the independent review organization considers them | ||||||
7 | appropriate, shall consider the following in reaching a | ||||||
8 | decision: | ||||||
9 | (1) the covered person's pertinent medical records; | ||||||
10 | (2) the covered person's health care provider's | ||||||
11 | recommendation; | ||||||
12 | (3) consulting reports from appropriate health care | ||||||
13 | providers and other documents submitted by the health | ||||||
14 | carrier or its designee utilization review organization , | ||||||
15 | the covered person, the covered person's authorized | ||||||
16 | representative, or the covered person's treating provider; | ||||||
17 | (4) the terms of coverage under the covered person's | ||||||
18 | health benefit plan with the health carrier to ensure that | ||||||
19 | the independent review organization's decision is not | ||||||
20 | contrary to the terms of coverage under the covered | ||||||
21 | person's health benefit plan with the health carrier , | ||||||
22 | unless the terms are inconsistent with applicable law ; | ||||||
23 | (5) the most appropriate practice guidelines, which | ||||||
24 | shall include applicable evidence-based standards and may | ||||||
25 | include any other practice guidelines developed by the | ||||||
26 | federal government, national or professional medical |
| |||||||
| |||||||
1 | societies, boards, and associations; | ||||||
2 | (6) any applicable clinical review criteria developed | ||||||
3 | and used by the health carrier or its designee utilization | ||||||
4 | review organization; and | ||||||
5 | (7) the opinion of the independent review | ||||||
6 | organization's clinical reviewer or reviewers after | ||||||
7 | considering items (1) through (6) of this subsection (i) to | ||||||
8 | the extent the information or documents are available and | ||||||
9 | the clinical reviewer or reviewers considers the | ||||||
10 | information or documents appropriate; and | ||||||
11 | (8) (blank). for a denial of coverage based on a | ||||||
12 | determination that the health care service or treatment | ||||||
13 | recommended or requested is experimental or | ||||||
14 | investigational, whether and to what extent: | ||||||
15 | (A) the recommended or requested health care | ||||||
16 | service or treatment has been approved by the federal | ||||||
17 | Food and Drug Administration, if applicable, for the | ||||||
18 | condition; | ||||||
19 | (B) medical or scientific evidence or | ||||||
20 | evidence-based standards demonstrate that the expected | ||||||
21 | benefits of the recommended or requested health care | ||||||
22 | service or treatment is more likely than not to be | ||||||
23 | beneficial to the covered person than any available | ||||||
24 | standard health care service or treatment and the | ||||||
25 | adverse risks of the recommended or requested health | ||||||
26 | care service or treatment would not be substantially |
| |||||||
| |||||||
1 | increased over those of available standard health care | ||||||
2 | services or treatments; or | ||||||
3 | (C) the terms of coverage under the covered | ||||||
4 | person's health benefit plan with the health carrier to | ||||||
5 | ensure that the health care service or treatment that | ||||||
6 | is the subject of the opinion is experimental or | ||||||
7 | investigational would otherwise be covered under the | ||||||
8 | terms of coverage of the covered person's health | ||||||
9 | benefit plan with the health carrier. | ||||||
10 | (j) Within 5 days after the date of receipt of all | ||||||
11 | necessary information, but in no event more than 45 days after | ||||||
12 | the date of receipt of the request for an external review, the | ||||||
13 | assigned independent review organization shall provide written | ||||||
14 | notice of its decision to uphold or reverse the adverse | ||||||
15 | determination or the final adverse determination to the | ||||||
16 | Director, the health carrier, the covered person , and, if | ||||||
17 | applicable, the covered person's authorized representative. In | ||||||
18 | reaching a decision, the assigned independent review | ||||||
19 | organization is not bound by any claim determinations reached | ||||||
20 | prior to the submission of information to the independent | ||||||
21 | review organization. In such cases, the following provisions | ||||||
22 | shall apply: | ||||||
23 | (1) The independent review organization shall include | ||||||
24 | in the notice: | ||||||
25 | (A) a general description of the reason for the | ||||||
26 | request for external review; |
| |||||||
| |||||||
1 | (B) the date the independent review organization | ||||||
2 | received the assignment from the Director health | ||||||
3 | carrier to conduct the external review; | ||||||
4 | (C) the time period during which the external | ||||||
5 | review was conducted; | ||||||
6 | (D) references to the evidence or documentation, | ||||||
7 | including the evidence-based standards, considered in | ||||||
8 | reaching its decision; | ||||||
9 | (E) the date of its decision; and | ||||||
10 | (F) the principal reason or reasons for its | ||||||
11 | decision, including what applicable, if any, | ||||||
12 | evidence-based standards that were a basis for its | ||||||
13 | decision ; and .
| ||||||
14 | (G) the rationale for its decision. | ||||||
15 | (2) (Blank). For reviews of experimental or | ||||||
16 | investigational treatments, the notice shall include the | ||||||
17 | following information: | ||||||
18 | (A) a description of the covered person's medical | ||||||
19 | condition; | ||||||
20 | (B) a description of the indicators relevant to | ||||||
21 | whether there is sufficient evidence to demonstrate | ||||||
22 | that the recommended or requested health care service | ||||||
23 | or treatment is more likely than not to be more | ||||||
24 | beneficial to the covered person than any available | ||||||
25 | standard health care services or treatments and the | ||||||
26 | adverse risks of the recommended or requested health |
| |||||||
| |||||||
1 | care service or treatment would not be substantially | ||||||
2 | increased over those of available standard health care | ||||||
3 | services or treatments; | ||||||
4 | (C) a description and analysis of any medical or | ||||||
5 | scientific evidence considered in reaching the | ||||||
6 | opinion; | ||||||
7 | (D) a description and analysis of any | ||||||
8 | evidence-based standards; | ||||||
9 | (E) whether the recommended or requested health | ||||||
10 | care service or treatment has been approved by the | ||||||
11 | federal Food and Drug Administration, for the | ||||||
12 | condition; | ||||||
13 | (F) whether medical or scientific evidence or | ||||||
14 | evidence-based standards demonstrate that the expected | ||||||
15 | benefits of the recommended or requested health care | ||||||
16 | service or treatment is more likely than not to be more | ||||||
17 | beneficial to the covered person than any available | ||||||
18 | standard health care service or treatment and the | ||||||
19 | adverse risks of the recommended or requested health | ||||||
20 | care service or treatment would not be substantially | ||||||
21 | increased over those of available standard health care | ||||||
22 | services or treatments; and | ||||||
23 | (G) the written opinion of the clinical reviewer, | ||||||
24 | including the reviewer's recommendation as to whether | ||||||
25 | the recommended or requested health care service or | ||||||
26 | treatment should be covered and the rationale for the |
| |||||||
| |||||||
1 | reviewer's recommendation. | ||||||
2 | (3) (Blank). In reaching a decision, the assigned | ||||||
3 | independent review organization is not bound by any | ||||||
4 | decisions or conclusions reached during the health | ||||||
5 | carrier's utilization review process or the health | ||||||
6 | carrier's internal grievance or appeals process. | ||||||
7 | (4) Upon receipt of a notice of a decision reversing | ||||||
8 | the adverse determination or final adverse determination, | ||||||
9 | the health carrier immediately shall approve the coverage | ||||||
10 | that was the subject of the adverse determination or final | ||||||
11 | adverse determination.
| ||||||
12 | (Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)
| ||||||
13 | (215 ILCS 180/40)
| ||||||
14 | Sec. 40. Expedited external review. | ||||||
15 | (a) A covered person or a covered person's authorized | ||||||
16 | representative may file a request for an expedited external | ||||||
17 | review with the Director health carrier either orally or in | ||||||
18 | writing: | ||||||
19 | (1) immediately after the date of receipt of a notice | ||||||
20 | prior to a final adverse determination as provided by | ||||||
21 | subsection (b) of Section 20 of this Act; | ||||||
22 | (2) immediately after the date of receipt of a notice | ||||||
23 | upon a final adverse determination as provided by | ||||||
24 | subsection (c) of Section 20 of this Act; or | ||||||
25 | (3) if a health carrier fails to provide a decision on |
| |||||||
| |||||||
1 | request for an expedited internal appeal within 48 hours as | ||||||
2 | provided by item (2) of Section 30 of this Act. | ||||||
3 | (b) Upon receipt of a request for an expedited external | ||||||
4 | review, the Director shall immediately send a copy of the | ||||||
5 | request to the health carrier. Immediately upon receipt of the | ||||||
6 | request for an expedited external review as provided under | ||||||
7 | subsections (b) and (c) of Section 20 , the health carrier shall | ||||||
8 | determine whether the request meets the reviewability | ||||||
9 | requirements set forth in items (1), (2), and (4) of subsection | ||||||
10 | (b) of Section 35. In such cases, the following provisions | ||||||
11 | shall apply: | ||||||
12 | (1) The health carrier shall immediately notify the | ||||||
13 | Director, the covered person , and, if applicable, the | ||||||
14 | covered person's authorized representative of its | ||||||
15 | eligibility determination. | ||||||
16 | (2) The notice of initial determination shall include a | ||||||
17 | statement informing the covered person and, if applicable, | ||||||
18 | the covered person's authorized representative that a | ||||||
19 | health carrier's initial determination that an external | ||||||
20 | review request is ineligible for review may be appealed to | ||||||
21 | the Director. | ||||||
22 | (3) The Director may determine that a request is | ||||||
23 | eligible for expedited external review notwithstanding a | ||||||
24 | health carrier's initial determination that the request is | ||||||
25 | ineligible and require that it be referred for external | ||||||
26 | review. |
| |||||||
| |||||||
1 | (4) In making a determination under item (3) of this | ||||||
2 | subsection (b), the Director's decision shall be made in | ||||||
3 | accordance with the terms of the covered person's health | ||||||
4 | benefit plan , unless such terms are inconsistent with | ||||||
5 | applicable law, and shall be subject to all applicable | ||||||
6 | provisions of this Act. | ||||||
7 | (5) The Director may specify the form for the health | ||||||
8 | carrier's notice of initial determination under this | ||||||
9 | subsection (b) and any supporting information to be | ||||||
10 | included in the notice. | ||||||
11 | (c) Upon receipt of the notice that the request meets the | ||||||
12 | reviewability requirements, determining that a request meets | ||||||
13 | the requirements of subsections (b) and (c) of Section 20, the | ||||||
14 | Director health
carrier shall immediately assign an | ||||||
15 | independent review organization from the list of approved | ||||||
16 | independent review organizations compiled and maintained by | ||||||
17 | the Director to conduct the expedited review. In such cases, | ||||||
18 | the following provisions shall apply: | ||||||
19 | (1) The assignment of an approved independent review | ||||||
20 | organization to conduct an external review in accordance | ||||||
21 | with this Section shall be made from those approved | ||||||
22 | independent review organizations qualified to conduct | ||||||
23 | external review as required by Sections 50 and 55 of this | ||||||
24 | Act.
| ||||||
25 | (2) The Director shall immediately notify the health | ||||||
26 | carrier of the name of the assigned independent review |
| |||||||
| |||||||
1 | organization. Immediately upon receipt from the Director | ||||||
2 | of the name of the independent review organization assigned | ||||||
3 | to conduct the external review assigning an independent | ||||||
4 | review organization to perform an expedited external | ||||||
5 | review , but in no case more than 24 hours after receiving | ||||||
6 | such notice assigning the independent review organization , | ||||||
7 | the health carrier or its designee utilization review | ||||||
8 | organization shall provide or transmit all necessary | ||||||
9 | documents and information considered in making the adverse | ||||||
10 | determination or final adverse determination to the | ||||||
11 | assigned independent review organization electronically or | ||||||
12 | by telephone or facsimile or any other available | ||||||
13 | expeditious method. | ||||||
14 | (3) If the health carrier or its utilization review | ||||||
15 | organization fails to provide the documents and | ||||||
16 | information within the specified timeframe, the assigned | ||||||
17 | independent review organization may terminate the external | ||||||
18 | review and make a decision to reverse the adverse | ||||||
19 | determination or final adverse determination. | ||||||
20 | (4) Within one business day after making the decision | ||||||
21 | to terminate the external review and make a decision to | ||||||
22 | reverse the adverse determination or final adverse | ||||||
23 | determination under item (3) of this subsection (c), the | ||||||
24 | independent review organization shall notify the Director, | ||||||
25 | the health carrier, the covered person , and, if applicable, | ||||||
26 | the covered person's authorized representative of its |
| |||||||
| |||||||
1 | decision to reverse the adverse determination or final | ||||||
2 | adverse determination .
| ||||||
3 | (d) In addition to the documents and information provided | ||||||
4 | by the health carrier or its utilization review organization | ||||||
5 | and any documents and information provided by the covered | ||||||
6 | person and the covered person's authorized representative, the | ||||||
7 | independent review organization , to the extent the information | ||||||
8 | or documents are available and the independent review | ||||||
9 | organization considers them appropriate, shall consider | ||||||
10 | information as required by subsection (i) of Section 35 of this | ||||||
11 | Act in reaching a decision. | ||||||
12 | (e) As expeditiously as the covered person's medical | ||||||
13 | condition or circumstances requires, but in no event more than | ||||||
14 | 72 hours after the date of receipt of the request for an | ||||||
15 | expedited external review 2 business days after the receipt of | ||||||
16 | all pertinent information , the assigned independent review | ||||||
17 | organization shall: | ||||||
18 | (1) make a decision to uphold or reverse the final | ||||||
19 | adverse determination; and | ||||||
20 | (2) notify the Director, the health carrier, the | ||||||
21 | covered person, the covered person's health care provider, | ||||||
22 | and , if applicable, the covered person's authorized | ||||||
23 | representative, of the decision. | ||||||
24 | (f) In reaching a decision, the assigned independent review | ||||||
25 | organization is not bound by any decisions or conclusions | ||||||
26 | reached during the health carrier's utilization review process |
| |||||||
| |||||||
1 | or the health carrier's internal appeal grievance process as | ||||||
2 | set forth in the Health Carrier Grievance Procedure Law Managed | ||||||
3 | Care Reform and Patient Rights Act .
| ||||||
4 | (g) Upon receipt of notice of a decision reversing the | ||||||
5 | adverse determination or final adverse determination, the | ||||||
6 | health carrier shall immediately approve the coverage that was | ||||||
7 | the subject of the adverse determination or final adverse | ||||||
8 | determination. | ||||||
9 | (h) If the notice provided pursuant to subsection (e) of | ||||||
10 | this Section was not in writing, then within Within 48 hours | ||||||
11 | after the date of providing that the notice required in item | ||||||
12 | (2) of subsection (e) , the assigned independent review | ||||||
13 | organization shall provide written confirmation of the | ||||||
14 | decision to the Director, the health carrier, the covered | ||||||
15 | person, and , if applicable, the covered person's authorized | ||||||
16 | representative including the information set forth in | ||||||
17 | subsection (j) of Section 35 of this Act as applicable. | ||||||
18 | (i) An expedited external review may not be provided for | ||||||
19 | retrospective adverse or final adverse determinations.
| ||||||
20 | (j) The assignment by the Director of an approved | ||||||
21 | independent review organization to conduct an external review | ||||||
22 | in accordance with this Section shall be done on a random basis | ||||||
23 | among those independent review organizations approved by the | ||||||
24 | Director pursuant to this Act. | ||||||
25 | (Source: P.A. 96-857, eff. 7-1-10; revised 9-16-10.)
|
| |||||||
| |||||||
1 | (215 ILCS 180/42 new) | ||||||
2 | Sec. 42. External review of experimental or | ||||||
3 | investigational treatment adverse determinations. | ||||||
4 | (a) Within 4 months after the date of receipt of a notice | ||||||
5 | of an adverse determination or final adverse determination that | ||||||
6 | involves a denial of coverage based on a determination that the | ||||||
7 | health care service or treatment recommended or requested is | ||||||
8 | experimental or investigational, a covered person or the | ||||||
9 | covered person's authorized representative may file a request | ||||||
10 | for an external review with the Director. | ||||||
11 | (b) The following provisions apply to cases concerning | ||||||
12 | expedited external reviews: | ||||||
13 | (1) A covered person or the covered person's authorized | ||||||
14 | representative may make an oral request for an expedited | ||||||
15 | external review of the adverse determination or final | ||||||
16 | adverse determination pursuant to subsection (a) of this | ||||||
17 | Section if the covered person's treating physician | ||||||
18 | certifies, in writing, that the recommended or requested | ||||||
19 | health care service or treatment that is the subject of the | ||||||
20 | request would be significantly less effective if not | ||||||
21 | promptly initiated. | ||||||
22 | (2) Upon receipt of a request for an expedited external | ||||||
23 | review, the Director shall immediately notify the health | ||||||
24 | carrier. | ||||||
25 | (3) The following provisions apply concerning notice: | ||||||
26 | (A) Upon notice of the request for an expedited |
| |||||||
| |||||||
1 | external review, the health carrier shall immediately | ||||||
2 | determine whether the request meets the reviewability | ||||||
3 | requirements of subsection (d) of this Section. The | ||||||
4 | health carrier shall immediately notify the Director | ||||||
5 | and the covered person and, if applicable, the covered | ||||||
6 | person's authorized representative of its eligibility | ||||||
7 | determination. | ||||||
8 | (B) The Director may specify the form for the | ||||||
9 | health carrier's notice of initial determination under | ||||||
10 | subdivision (A) of this item (3) and any supporting | ||||||
11 | information to be included in the notice. | ||||||
12 | (C) The notice of initial determination under | ||||||
13 | subdivision (A) of this item (3) shall include a | ||||||
14 | statement informing the covered person and, if | ||||||
15 | applicable, the covered person's authorized | ||||||
16 | representative that a health carrier's initial | ||||||
17 | determination that the external review request is | ||||||
18 | ineligible for review may be appealed to the Director. | ||||||
19 | (4) The following provisions apply concerning the | ||||||
20 | Director's determination: | ||||||
21 | (A) The Director may determine that a request is | ||||||
22 | eligible for external review under subsection (d) of | ||||||
23 | this Section notwithstanding a health carrier's | ||||||
24 | initial determination that the request is ineligible | ||||||
25 | and require that it be referred for external review. | ||||||
26 | (B) In making a determination under subdivision |
| |||||||
| |||||||
1 | (A) of this item (4), the Director's decision shall be | ||||||
2 | made in accordance with the terms of the covered | ||||||
3 | person's health benefit plan, unless such terms are | ||||||
4 | inconsistent with applicable law, and shall be subject | ||||||
5 | to all applicable provisions of this Act. | ||||||
6 | (5) Upon receipt of the notice that the expedited | ||||||
7 | external review request meets the reviewability | ||||||
8 | requirements of subsection (d) of this Section, the | ||||||
9 | Director shall immediately assign an independent review | ||||||
10 | organization to review the expedited request from the list | ||||||
11 | of approved independent review organizations compiled and | ||||||
12 | maintained by the Director and notify the health carrier of | ||||||
13 | the name of the assigned independent review organization. | ||||||
14 | (6) At the time the health carrier receives the notice | ||||||
15 | of the assigned independent review organization, the | ||||||
16 | health carrier or its designee utilization review | ||||||
17 | organization shall provide or transmit all necessary | ||||||
18 | documents and information considered in making the adverse | ||||||
19 | determination or final adverse determination to the | ||||||
20 | assigned independent review organization electronically or | ||||||
21 | by telephone or facsimile or any other available | ||||||
22 | expeditious method. | ||||||
23 | (c) Except for a request for an expedited external review | ||||||
24 | made pursuant to subsection (b) of this Section, within one | ||||||
25 | business day after the date of receipt of a request for | ||||||
26 | external review, the Director shall send a copy of the request |
| |||||||
| |||||||
1 | to the health carrier. | ||||||
2 | (d) Within 5 business days following the date of receipt of | ||||||
3 | the external review request, the health carrier shall complete | ||||||
4 | a preliminary review of the request to determine whether: | ||||||
5 | (1) the individual is or was a covered person in the | ||||||
6 | health benefit plan at the time the health care service was | ||||||
7 | recommended or requested or, in the case of a retrospective | ||||||
8 | review, at the time the health care service was provided; | ||||||
9 | (2) the recommended or requested health care service or | ||||||
10 | treatment that is the subject of the adverse determination | ||||||
11 | or final adverse determination is a covered benefit under | ||||||
12 | the covered person's health benefit plan except for the | ||||||
13 | health carrier's determination that the service or | ||||||
14 | treatment is experimental or investigational for a | ||||||
15 | particular medical condition and is not explicitly listed | ||||||
16 | as an excluded benefit under the covered person's health | ||||||
17 | benefit plan with the health carrier; | ||||||
18 | (3) the covered person's health care provider has | ||||||
19 | certified that one of the following situations is | ||||||
20 | applicable: | ||||||
21 | (A) standard health care services or treatments | ||||||
22 | have not been effective in improving the condition of | ||||||
23 | the covered person; | ||||||
24 | (B) standard health care services or treatments | ||||||
25 | are not medically appropriate for the covered person; | ||||||
26 | or |
| |||||||
| |||||||
1 | (C) there is no available standard health care | ||||||
2 | service or treatment covered by the health carrier that | ||||||
3 | is more beneficial than the recommended or requested | ||||||
4 | health care service or treatment; | ||||||
5 | (4) the covered person's health care provider: | ||||||
6 | (A) has recommended a health care service or | ||||||
7 | treatment that the physician certifies, in writing, is | ||||||
8 | likely to be more beneficial to the covered person, in | ||||||
9 | the physician's opinion, than any available standard | ||||||
10 | health care services or treatments; or | ||||||
11 | (B) who is a licensed, board certified or board | ||||||
12 | eligible physician qualified to practice in the area of | ||||||
13 | medicine appropriate to treat the covered person's | ||||||
14 | condition, has certified in writing that | ||||||
15 | scientifically valid studies using accepted protocols | ||||||
16 | demonstrate that the health care service or treatment | ||||||
17 | requested by the covered person that is the subject of | ||||||
18 | the adverse determination or final adverse | ||||||
19 | determination is likely to be more beneficial to the | ||||||
20 | covered person than any available standard health care | ||||||
21 | services or treatments; | ||||||
22 | (5) the covered person has exhausted the health | ||||||
23 | carrier's internal appeal process as set forth in the | ||||||
24 | Health Carrier Grievance Procedure Act, unless the covered | ||||||
25 | person is not required to exhaust the health carrier's | ||||||
26 | internal appeal process pursuant to Section 30 of this Act; |
| |||||||
| |||||||
1 | and | ||||||
2 | (6) the covered person has provided all the information | ||||||
3 | and forms required to process an external review, as | ||||||
4 | specified in this Act. | ||||||
5 | (e) The following provisions apply concerning requests: | ||||||
6 | (1) Within one business day after completion of the | ||||||
7 | preliminary review, the health carrier shall notify the | ||||||
8 | Director and covered person and, if applicable, the covered | ||||||
9 | person's authorized representative in writing whether the | ||||||
10 | request is complete and eligible for external review. | ||||||
11 | (2) If the request: | ||||||
12 | (A) is not complete, then the health carrier shall | ||||||
13 | inform the Director and the covered person and, if | ||||||
14 | applicable, the covered person's authorized | ||||||
15 | representative in writing and include in the notice | ||||||
16 | what information or materials are required by this Act | ||||||
17 | to make the request complete; or | ||||||
18 | (B) is not eligible for external review, then the | ||||||
19 | health carrier shall inform the Director and the | ||||||
20 | covered person and, if applicable, the covered | ||||||
21 | person's authorized representative in writing and | ||||||
22 | include in the notice the reasons for its | ||||||
23 | ineligibility. | ||||||
24 | (3) The Department may specify the form for the health | ||||||
25 | carrier's notice of initial determination under this | ||||||
26 | subsection (e) and any supporting information to be |
| |||||||
| |||||||
1 | included in the notice. | ||||||
2 | (4) The notice of initial determination of | ||||||
3 | ineligibility shall include a statement informing the | ||||||
4 | covered person and, if applicable, the covered person's | ||||||
5 | authorized representative that a health carrier's initial | ||||||
6 | determination that the external review request is | ||||||
7 | ineligible for review may be appealed to the Director by | ||||||
8 | filing a complaint with the Director. | ||||||
9 | (5) Notwithstanding a health carrier's initial | ||||||
10 | determination that the request is ineligible for external | ||||||
11 | review, the Director may determine that a request is | ||||||
12 | eligible for external review and require that it be | ||||||
13 | referred for external review. In making such | ||||||
14 | determination, the Director's decision shall be in | ||||||
15 | accordance with the terms of the covered person's health | ||||||
16 | benefit plan, unless such terms are inconsistent with | ||||||
17 | applicable law, and shall be subject to all applicable | ||||||
18 | provisions of this Act. | ||||||
19 | (f) Whenever a request for external review is determined | ||||||
20 | eligible for external review, the health carrier shall notify | ||||||
21 | the Director and the covered person and, if applicable, the | ||||||
22 | covered person's authorized representative. | ||||||
23 | (g) Whenever the Director receives notice that a request is | ||||||
24 | eligible for external review following the preliminary review | ||||||
25 | conducted pursuant to this Section, within one business day | ||||||
26 | after the date of receipt of the notice, the Director shall: |
| |||||||
| |||||||
1 | (1) assign an independent review organization from the | ||||||
2 | list of approved independent review organizations compiled | ||||||
3 | and maintained by the Director pursuant to this Act and | ||||||
4 | notify the health carrier of the name of the assigned | ||||||
5 | independent review organization; and | ||||||
6 | (2) notify in writing the covered person and, if | ||||||
7 | applicable, the covered person's authorized representative | ||||||
8 | of the request's eligibility and acceptance for external | ||||||
9 | review and the name of the independent review organization. | ||||||
10 | The Director shall include in the notice provided to the | ||||||
11 | covered person and, if applicable, the covered person's | ||||||
12 | authorized representative a statement that the covered person | ||||||
13 | or the covered person's authorized representative may, within 5 | ||||||
14 | business days following the date of receipt of the notice | ||||||
15 | provided pursuant to item (2) of this subsection (g), submit in | ||||||
16 | writing to the assigned independent review organization | ||||||
17 | additional information that the independent review | ||||||
18 | organization shall consider when conducting the external | ||||||
19 | review. The independent review organization is not required to, | ||||||
20 | but may, accept and consider additional information submitted | ||||||
21 | after 5 business days. | ||||||
22 | (h) The following provisions apply concerning assignments | ||||||
23 | and clinical reviews: | ||||||
24 | (1) Within one business day after the receipt of the | ||||||
25 | notice of assignment to conduct the external review | ||||||
26 | pursuant to subsection (g) of this Section, the assigned |
| |||||||
| |||||||
1 | independent review organization shall select one or more | ||||||
2 | clinical reviewers, as it determines is appropriate, | ||||||
3 | pursuant to item (2) of this subsection (h) to conduct the | ||||||
4 | external review. | ||||||
5 | (2) The provisions of this item (2) apply concerning | ||||||
6 | the selection of reviewers: | ||||||
7 | (A) In selecting clinical reviewers pursuant to | ||||||
8 | item (1) of this subsection (h), the assigned | ||||||
9 | independent review organization shall select | ||||||
10 | physicians or other health care professionals who meet | ||||||
11 | the minimum qualifications described in Section 55 of | ||||||
12 | this Act and, through clinical experience in the past 3 | ||||||
13 | years, are experts in the treatment of the covered | ||||||
14 | person's condition and knowledgeable about the | ||||||
15 | recommended or requested health care service or | ||||||
16 | treatment. | ||||||
17 | (B) Neither the covered person, the covered | ||||||
18 | person's authorized representative, if applicable, nor | ||||||
19 | the health carrier shall choose or control the choice | ||||||
20 | of the physicians or other health care professionals to | ||||||
21 | be selected to conduct the external review. | ||||||
22 | (3) In accordance with subsection (l) of this Section, | ||||||
23 | each clinical reviewer shall provide a written opinion to | ||||||
24 | the assigned independent review organization on whether | ||||||
25 | the recommended or requested health care service or | ||||||
26 | treatment should be covered. |
| |||||||
| |||||||
1 | (4) In reaching an opinion, clinical reviewers are not | ||||||
2 | bound by any decisions or conclusions reached during the | ||||||
3 | health carrier's utilization review process or the health | ||||||
4 | carrier's internal appeal process. | ||||||
5 | (i) Within 5 business days after the date of receipt of the | ||||||
6 | notice provided pursuant to subsection (g) of this Section, the | ||||||
7 | health carrier or its designee utilization review organization | ||||||
8 | shall provide to the assigned independent review organization | ||||||
9 | the documents and any information considered in making the | ||||||
10 | adverse determination or final adverse determination; in such | ||||||
11 | cases, the following provisions shall apply: | ||||||
12 | (1) Except as provided in item (2) of this subsection | ||||||
13 | (i), failure by the health carrier or its utilization | ||||||
14 | review organization to provide the documents and | ||||||
15 | information within the specified time frame shall not delay | ||||||
16 | the conduct of the external review. | ||||||
17 | (2) If the health carrier or its utilization review | ||||||
18 | organization fails to provide the documents and | ||||||
19 | information within the specified time frame, the assigned | ||||||
20 | independent review organization may terminate the external | ||||||
21 | review and make a decision to reverse the adverse | ||||||
22 | determination or final adverse determination. | ||||||
23 | (3) Immediately upon making the decision to terminate | ||||||
24 | the external review and make a decision to reverse the | ||||||
25 | adverse determination or final adverse determination under | ||||||
26 | item (2) of this subsection (i), the independent review |
| |||||||
| |||||||
1 | organization shall notify the Director, the health | ||||||
2 | carrier, the covered person, and, if applicable, the | ||||||
3 | covered person's authorized representative of its decision | ||||||
4 | to reverse the adverse determination. | ||||||
5 | (j) Upon receipt of the information from the health carrier | ||||||
6 | or its utilization review organization, each clinical reviewer | ||||||
7 | selected pursuant to subsection (h) of this Section shall | ||||||
8 | review all of the information and documents and any other | ||||||
9 | information submitted in writing to the independent review | ||||||
10 | organization by the covered person and the covered person's | ||||||
11 | authorized representative. | ||||||
12 | (k) Upon receipt of any information submitted by the | ||||||
13 | covered person or the covered person's authorized | ||||||
14 | representative, the independent review organization shall | ||||||
15 | forward the information to the health carrier within one | ||||||
16 | business day. In such cases, the following provisions shall | ||||||
17 | apply: | ||||||
18 | (1) Upon receipt of the information, if any, the health | ||||||
19 | carrier may reconsider its adverse determination or final | ||||||
20 | adverse determination that is the subject of the external | ||||||
21 | review. | ||||||
22 | (2) Reconsideration by the health carrier of its | ||||||
23 | adverse determination or final adverse determination shall | ||||||
24 | not delay or terminate the external review. | ||||||
25 | (3) The external review may be terminated only if the | ||||||
26 | health carrier decides, upon completion of its |
| |||||||
| |||||||
1 | reconsideration, to reverse its adverse determination or | ||||||
2 | final adverse determination and provide coverage or | ||||||
3 | payment for the health care service that is the subject of | ||||||
4 | the adverse determination or final adverse determination. | ||||||
5 | In such cases, the following provisions shall apply: | ||||||
6 | (A) Immediately upon making its decision to | ||||||
7 | reverse its adverse determination or final adverse | ||||||
8 | determination, the health carrier shall notify the | ||||||
9 | Director, the covered person and, if applicable, the | ||||||
10 | covered person's authorized representative, and the | ||||||
11 | assigned independent review organization in writing of | ||||||
12 | its decision. | ||||||
13 | (B) Upon notice from the health carrier that the | ||||||
14 | health carrier has made a decision to reverse its | ||||||
15 | adverse determination or final adverse determination, | ||||||
16 | the assigned independent review organization shall | ||||||
17 | terminate the external review. | ||||||
18 | (l) The following provisions apply concerning clinical | ||||||
19 | review opinions: | ||||||
20 | (1) Except as provided in item (3) of this subsection | ||||||
21 | (l), within 20 days after being selected in accordance with | ||||||
22 | subsection (h) of this Section to conduct the external | ||||||
23 | review, each clinical reviewer shall provide an opinion to | ||||||
24 | the assigned independent review organization on whether | ||||||
25 | the recommended or requested health care service or | ||||||
26 | treatment should be covered. |
| |||||||
| |||||||
1 | (2) Except for an opinion provided pursuant to item (3) | ||||||
2 | of this subsection (l), each clinical reviewer's opinion | ||||||
3 | shall be in writing and include the following information: | ||||||
4 | (A) a description of the covered person's medical | ||||||
5 | condition; | ||||||
6 | (B) a description of the indicators relevant to | ||||||
7 | determining whether there is sufficient evidence to | ||||||
8 | demonstrate that the recommended or requested health | ||||||
9 | care service or treatment is more likely than not to be | ||||||
10 | beneficial to the covered person than any available | ||||||
11 | standard health care services or treatments and the | ||||||
12 | adverse risks of the recommended or requested health | ||||||
13 | care service or treatment would not be substantially | ||||||
14 | increased over those of available standard health care | ||||||
15 | services or treatments; | ||||||
16 | (C) a description and analysis of any medical or | ||||||
17 | scientific evidence considered in reaching the | ||||||
18 | opinion; | ||||||
19 | (D) a description and analysis of any | ||||||
20 | evidence-based standard; and | ||||||
21 | (E) information on whether the reviewer's | ||||||
22 | rationale for the opinion is based on clause (A) or (B) | ||||||
23 | of item (5) of subsection (m) of this Section. | ||||||
24 | (3) The provisions of this item (3) apply concerning | ||||||
25 | the timing of opinions: | ||||||
26 | (A) For an expedited external review, each |
| |||||||
| |||||||
1 | clinical reviewer shall provide an opinion orally or in | ||||||
2 | writing to the assigned independent review | ||||||
3 | organization as expeditiously as the covered person's | ||||||
4 | medical condition or circumstances requires, but in no | ||||||
5 | event more than 5 calendar days after being selected in | ||||||
6 | accordance with subsection (h) of this Section. | ||||||
7 | (B) If the opinion provided pursuant to | ||||||
8 | subdivision (A) of this item (3) was not in writing, | ||||||
9 | then within 48 hours following the date the opinion was | ||||||
10 | provided, the clinical reviewer shall provide written | ||||||
11 | confirmation of the opinion to the assigned | ||||||
12 | independent review organization and include the | ||||||
13 | information required under item (2) of this subsection | ||||||
14 | (l). | ||||||
15 | (m) In addition to the documents and information provided | ||||||
16 | by the health carrier or its utilization review organization | ||||||
17 | and the covered person and the covered person's authorized | ||||||
18 | representative, if any, each clinical reviewer selected | ||||||
19 | pursuant to subsection (h) of this Section, to the extent the | ||||||
20 | information or documents are available and the clinical | ||||||
21 | reviewer considers appropriate, shall consider the following | ||||||
22 | in reaching a decision: | ||||||
23 | (1) the covered person's pertinent medical records; | ||||||
24 | (2) the covered person's health care provider's | ||||||
25 | recommendation; | ||||||
26 | (3) consulting reports from appropriate health care |
| |||||||
| |||||||
1 | providers and other documents submitted by the health | ||||||
2 | carrier or its designee utilization review organization, | ||||||
3 | the covered person, the covered person's authorized | ||||||
4 | representative, or the covered person's treating physician | ||||||
5 | or health care professional; | ||||||
6 | (4) the terms of coverage under the covered person's | ||||||
7 | health benefit plan with the health carrier to ensure that, | ||||||
8 | but for the health carrier's determination that the | ||||||
9 | recommended or requested health care service or treatment | ||||||
10 | that is the subject of the opinion is experimental or | ||||||
11 | investigational, the reviewer's opinion is not contrary to | ||||||
12 | the terms of coverage under the covered person's health | ||||||
13 | benefit plan with the health carrier; and | ||||||
14 | (5) whether (A) the recommended or requested health | ||||||
15 | care service or treatment has been approved by the federal | ||||||
16 | Food and Drug Administration, if applicable, for the | ||||||
17 | condition or (B) medical or scientific evidence or | ||||||
18 | evidence-based standards demonstrate that the expected | ||||||
19 | benefits of the recommended or requested health care | ||||||
20 | service or treatment is more likely than not to be | ||||||
21 | beneficial to the covered person than any available | ||||||
22 | standard health care service or treatment and the adverse | ||||||
23 | risks of the recommended or requested health care service | ||||||
24 | or treatment would not be substantially increased over | ||||||
25 | those of available standard health care services or | ||||||
26 | treatments. |
| |||||||
| |||||||
1 | (n) The following provisions apply concerning decisions, | ||||||
2 | notices, and recommendations: | ||||||
3 | (1) The provisions of this item (1) apply concerning | ||||||
4 | decisions and notices: | ||||||
5 | (A) Except as provided in subdivision (B) of this | ||||||
6 | item (1), within 20 days after the date it receives the | ||||||
7 | opinion of each clinical reviewer, the assigned | ||||||
8 | independent review organization, in accordance with | ||||||
9 | item (2) of this subsection (n), shall make a decision | ||||||
10 | and provide written notice of the decision to the | ||||||
11 | Director, the health carrier, the covered person, and | ||||||
12 | the covered person's authorized representative, if | ||||||
13 | applicable. | ||||||
14 | (B) For an expedited external review, within 48 | ||||||
15 | hours after the date it receives the opinion of each | ||||||
16 | clinical reviewer, the assigned independent review | ||||||
17 | organization, in accordance with item (2) of this | ||||||
18 | subsection (n), shall make a decision and provide | ||||||
19 | notice of the decision orally or in writing to the | ||||||
20 | Director, the health carrier, the covered person, and | ||||||
21 | the covered person's authorized representative, if | ||||||
22 | applicable. If such notice is not in writing, within 48 | ||||||
23 | hours after the date of providing that notice, the | ||||||
24 | assigned independent review organization shall provide | ||||||
25 | written confirmation of the decision to the Director, | ||||||
26 | the health carrier, the covered person, and the covered |
| |||||||
| |||||||
1 | person's authorized representative, if applicable. | ||||||
2 | (2) The provisions of this item (2) apply concerning | ||||||
3 | recommendations: | ||||||
4 | (A) If a majority of the clinical reviewers | ||||||
5 | recommend that the recommended or requested health | ||||||
6 | care service or treatment should be covered, then the | ||||||
7 | independent review organization shall make a decision | ||||||
8 | to reverse the health carrier's adverse determination | ||||||
9 | or final adverse determination. | ||||||
10 | (B) If a majority of the clinical reviewers | ||||||
11 | recommend that the recommended or requested health | ||||||
12 | care service or treatment should not be covered, the | ||||||
13 | independent review organization shall make a decision | ||||||
14 | to uphold the health carrier's adverse determination | ||||||
15 | or final adverse determination. | ||||||
16 | (C) The provisions of this subdivision (C) apply to | ||||||
17 | cases in which the clinical reviewers are evenly split: | ||||||
18 | (i) If the clinical reviewers are evenly split | ||||||
19 | as to whether the recommended or requested health | ||||||
20 | care service or treatment should be covered, then | ||||||
21 | the independent review organization shall obtain | ||||||
22 | the opinion of an additional clinical reviewer in | ||||||
23 | order for the independent review organization to | ||||||
24 | make a decision based on the opinions of a majority | ||||||
25 | of the clinical reviewers pursuant to subdivision | ||||||
26 | (A) or (B) of this item (2). |
| |||||||
| |||||||
1 | (ii) The additional clinical reviewer selected | ||||||
2 | under clause (i) of this subdivision (C) shall use | ||||||
3 | the same information to reach an opinion as the | ||||||
4 | clinical reviewers who have already submitted | ||||||
5 | their opinions. | ||||||
6 | (iii) The selection of the additional clinical | ||||||
7 | reviewer under this subdivision (C) shall not | ||||||
8 | extend the time within which the assigned | ||||||
9 | independent review organization is required to | ||||||
10 | make a decision based on the opinions of the | ||||||
11 | clinical reviewers. | ||||||
12 | (o) The independent review organization shall include in | ||||||
13 | the notice provided pursuant to subsection (n) of this Section: | ||||||
14 | (1) a general description of the reason for the request | ||||||
15 | for external review; | ||||||
16 | (2) the written opinion of each clinical reviewer, | ||||||
17 | including the recommendation of each clinical reviewer as | ||||||
18 | to whether the recommended or requested health care service | ||||||
19 | or treatment should be covered and the rationale for the | ||||||
20 | reviewer's recommendation; | ||||||
21 | (3) the date the independent review organization | ||||||
22 | received the assignment from the Director to conduct the | ||||||
23 | external review; | ||||||
24 | (4) the time period during which the external review | ||||||
25 | was conducted; | ||||||
26 | (5) the date of its decision; |
| |||||||
| |||||||
1 | (6) the principal reason or reasons for its decision; | ||||||
2 | and | ||||||
3 | (7) the rationale for its decision. | ||||||
4 | (p) Upon receipt of a notice of a decision reversing the | ||||||
5 | adverse determination or final adverse determination, the | ||||||
6 | health carrier shall immediately approve the coverage that was | ||||||
7 | the subject of the adverse determination or final adverse | ||||||
8 | determination. | ||||||
9 | (q) The assignment by the Director of an approved | ||||||
10 | independent review organization to conduct an external review | ||||||
11 | in accordance with this Section shall be done on a random basis | ||||||
12 | among those independent review organizations approved by the | ||||||
13 | Director pursuant to this Act.
| ||||||
14 | (215 ILCS 180/55)
| ||||||
15 | Sec. 55. Minimum qualifications for independent review | ||||||
16 | organizations.
| ||||||
17 | (a) To be approved to conduct external reviews, an | ||||||
18 | independent review organization shall have and maintain | ||||||
19 | written policies and procedures that govern all aspects of both | ||||||
20 | the standard external review process and the expedited external | ||||||
21 | review process set forth in this Act that include, at a | ||||||
22 | minimum: | ||||||
23 | (1) a quality assurance mechanism that ensures that: | ||||||
24 | (A) external reviews are conducted within the | ||||||
25 | specified timeframes and required notices are provided |
| |||||||
| |||||||
1 | in a timely manner; | ||||||
2 | (B) selection of qualified and impartial clinical | ||||||
3 | reviewers to conduct external reviews on behalf of the | ||||||
4 | independent review organization and suitable matching | ||||||
5 | of reviewers to specific cases and that the independent | ||||||
6 | review organization employs or contracts with an | ||||||
7 | adequate number of clinical reviewers to meet this | ||||||
8 | objective; | ||||||
9 | (C) for adverse determinations involving | ||||||
10 | experimental or investigational treatments, in | ||||||
11 | assigning clinical reviewers, the independent review | ||||||
12 | organization selects physicians or other health care | ||||||
13 | professionals who, through clinical experience in the | ||||||
14 | past 3 years, are experts in the treatment of the | ||||||
15 | covered person's condition and knowledgeable about the | ||||||
16 | recommended or requested health care service or | ||||||
17 | treatment; | ||||||
18 | (D) the health carrier, the covered person, and the | ||||||
19 | covered person's authorized representative shall not | ||||||
20 | choose or control the choice of the physicians or other | ||||||
21 | health care professionals to be selected to conduct the | ||||||
22 | external review; | ||||||
23 | (E) confidentiality of medical and treatment | ||||||
24 | records and clinical review criteria; and | ||||||
25 | (F) any person employed by or under contract with | ||||||
26 | the independent review organization adheres to the |
| |||||||
| |||||||
1 | requirements of this Act; | ||||||
2 | (2) a toll-free telephone service operating on a | ||||||
3 | 24-hour-day, 7-day-a-week basis that accepts, receives, | ||||||
4 | and records information related to external reviews and | ||||||
5 | provides appropriate instructions; and | ||||||
6 | (3) an agreement to maintain and provide to the | ||||||
7 | Director the information set out in Section 70 of this Act. | ||||||
8 | (b) All clinical reviewers assigned by an independent | ||||||
9 | review organization to conduct external reviews shall be | ||||||
10 | physicians or other appropriate health care providers who meet | ||||||
11 | the following minimum qualifications:
| ||||||
12 | (1) be an expert in the treatment of the covered | ||||||
13 | person's medical condition that is the subject of the | ||||||
14 | external review; | ||||||
15 | (2) be knowledgeable about the recommended health care | ||||||
16 | service or treatment through recent or current actual | ||||||
17 | clinical experience treating patients with the same or | ||||||
18 | similar medical condition of the covered person; | ||||||
19 | (3) hold a non-restricted license in a state of the | ||||||
20 | United States and, for physicians, a current certification | ||||||
21 | by a recognized American medical specialty board in the | ||||||
22 | area or areas appropriate to the subject of the external | ||||||
23 | review; and | ||||||
24 | (4) have no history of disciplinary actions or | ||||||
25 | sanctions, including loss of staff privileges or | ||||||
26 | participation restrictions, that have been taken or are |
| |||||||
| |||||||
1 | pending by any hospital, governmental agency or unit, or | ||||||
2 | regulatory body that raise a substantial question as to the | ||||||
3 | clinical reviewer's physical, mental, or professional | ||||||
4 | competence or moral character. | ||||||
5 | (c) In addition to the requirements set forth in subsection | ||||||
6 | (a), an independent review organization may not own or control, | ||||||
7 | be a subsidiary of, or in any way be owned, or controlled by, | ||||||
8 | or exercise control with a health benefit plan, a national, | ||||||
9 | State, or local trade association of health benefit plans, or a | ||||||
10 | national, State, or local trade association of health care | ||||||
11 | providers. | ||||||
12 | (d) Conflicts of interest prohibited.
In addition to the | ||||||
13 | requirements set forth in subsections (a), (b), and (c) of this | ||||||
14 | Section, to be approved pursuant to this Act to conduct an | ||||||
15 | external review of a specified case, neither the independent | ||||||
16 | review organization selected to conduct the external review nor | ||||||
17 | any clinical reviewer assigned by the independent organization | ||||||
18 | to conduct the external review may have a material | ||||||
19 | professional, familial or financial conflict of interest with | ||||||
20 | any of the following: | ||||||
21 | (1) the health carrier that is the subject of the | ||||||
22 | external review; | ||||||
23 | (2) the covered person whose treatment is the subject | ||||||
24 | of the external review or the covered person's authorized | ||||||
25 | representative; | ||||||
26 | (3) any officer, director or management employee of the |
| |||||||
| |||||||
1 | health carrier that is the subject of the external review; | ||||||
2 | (4) the health care provider, the health care | ||||||
3 | provider's medical group or independent practice | ||||||
4 | association recommending the health care service or | ||||||
5 | treatment that is the subject of the external review; | ||||||
6 | (5) the facility at which the recommended health care | ||||||
7 | service or treatment would be provided; or | ||||||
8 | (6) the developer or manufacturer of the principal | ||||||
9 | drug, device, procedure, or other therapy being | ||||||
10 | recommended for the covered person whose treatment is the | ||||||
11 | subject of the external review.
| ||||||
12 | (e) An independent review organization that is accredited | ||||||
13 | by a nationally recognized private accrediting entity that has | ||||||
14 | independent review accreditation standards that the Director | ||||||
15 | has determined are equivalent to or exceed the minimum | ||||||
16 | qualifications of this Section shall be presumed to be in | ||||||
17 | compliance with this Section and shall be eligible for approval | ||||||
18 | under this Act. | ||||||
19 | (f) An independent review organization shall be unbiased. | ||||||
20 | An independent review organization shall establish and | ||||||
21 | maintain written procedures to ensure that it is unbiased in | ||||||
22 | addition to any other procedures required under this Section. | ||||||
23 | (g) Nothing in this Act precludes or shall be interpreted | ||||||
24 | to preclude a health carrier from contracting with approved | ||||||
25 | independent review organizations to conduct external reviews | ||||||
26 | assigned to it from such health carrier .
|
| |||||||
| |||||||
1 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
2 | (215 ILCS 180/65)
| ||||||
3 | Sec. 65. External review reporting requirements. | ||||||
4 | (a) Each health carrier shall maintain written records in | ||||||
5 | the aggregate , by state, and for each type of health benefit | ||||||
6 | plan offered by the health carrier on all requests for external | ||||||
7 | review that the health carrier received notice from the | ||||||
8 | Director for each calendar year and submit a report to the | ||||||
9 | Director in the format specified by the Director by March 1 of | ||||||
10 | each year. | ||||||
11 | (a-5) An independent review organization assigned pursuant | ||||||
12 | to this Act to conduct an external review shall maintain | ||||||
13 | written records in the aggregate by state and by health carrier | ||||||
14 | on all requests for external review for which it conducted an | ||||||
15 | external review during a calendar year and submit a report in | ||||||
16 | the format specified by the Director by March 1 of each year. | ||||||
17 | (a-10) The report required by subsection (a-5) shall | ||||||
18 | include in the aggregate by state, and for each health carrier: | ||||||
19 | (1) the total number of requests for external review; | ||||||
20 | (2) the number of requests for external review resolved | ||||||
21 | and, of those resolved, the number resolved upholding the | ||||||
22 | adverse determination or final adverse determination and | ||||||
23 | the number resolved reversing the adverse determination or | ||||||
24 | final adverse determination; | ||||||
25 | (3) the average length of time for resolution; |
| |||||||
| |||||||
1 | (4) a summary of the types of coverages or cases for | ||||||
2 | which an external review was sought, as provided in the | ||||||
3 | format required by the Director; | ||||||
4 | (5) the number of external reviews pursuant to Section | ||||||
5 | 8G of this Act that were terminated as the result of a | ||||||
6 | reconsideration by the health carrier of its adverse | ||||||
7 | determination or final adverse determination after the | ||||||
8 | receipt of additional information from the covered person | ||||||
9 | or the covered person's authorized representative; and | ||||||
10 | (6) any other information the Director may request or | ||||||
11 | require. | ||||||
12 | (a-15) The independent review organization shall retain | ||||||
13 | the written records required pursuant to this Section for at | ||||||
14 | least 3 years. | ||||||
15 | (b) The report required under subsection (a) of this | ||||||
16 | Section shall include in the aggregate , by state, and by type | ||||||
17 | of health benefit plan :
| ||||||
18 | (1) the total number of requests for external review; | ||||||
19 | (2) the total number of requests for expedited external | ||||||
20 | review;
| ||||||
21 | (3) the total number of requests for external review | ||||||
22 | denied; | ||||||
23 | (4) the number of requests for external review | ||||||
24 | resolved, including: | ||||||
25 | (A) the number of requests for external review | ||||||
26 | resolved upholding the adverse determination or final |
| |||||||
| |||||||
1 | adverse determination; | ||||||
2 | (B) the number of requests for external review | ||||||
3 | resolved reversing the adverse determination or final | ||||||
4 | adverse determination; | ||||||
5 | (C) the number of requests for expedited external | ||||||
6 | review resolved upholding the adverse determination or | ||||||
7 | final adverse determination; and | ||||||
8 | (D) the number of requests for expedited external | ||||||
9 | review resolved reversing the adverse determination or | ||||||
10 | final adverse determination; | ||||||
11 | (5) the average length of time for resolution for an | ||||||
12 | external review; | ||||||
13 | (6) the average length of time for resolution for an | ||||||
14 | expedited external review; | ||||||
15 | (7) a summary of the types of coverages or cases for | ||||||
16 | which an external review was sought, as specified below:
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17 | (A) denial of care or treatment (dissatisfaction | ||||||
18 | regarding prospective non-authorization of a request | ||||||
19 | for care or treatment recommended by a provider | ||||||
20 | excluding diagnostic procedures and referral requests; | ||||||
21 | partial approvals and care terminations are also | ||||||
22 | considered to be denials); | ||||||
23 | (B) denial of diagnostic procedure | ||||||
24 | (dissatisfaction regarding prospective | ||||||
25 | non-authorization of a request for a diagnostic | ||||||
26 | procedure recommended by a provider; partial approvals |
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1 | are also considered to be denials); | ||||||
2 | (C) denial of referral request (dissatisfaction | ||||||
3 | regarding non-authorization of a request for a | ||||||
4 | referral to another provider recommended by a PCP); | ||||||
5 | (D) claims and utilization review (dissatisfaction | ||||||
6 | regarding the concurrent or retrospective evaluation | ||||||
7 | of the coverage, medical necessity, efficiency or | ||||||
8 | appropriateness of health care services or treatment | ||||||
9 | plans; prospective "Denials of care or treatment", | ||||||
10 | "Denials of diagnostic procedures" and "Denials of | ||||||
11 | referral requests" should not be classified in this | ||||||
12 | category, but the appropriate one above);
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13 | (8) the number of external reviews that were terminated | ||||||
14 | as the result of a reconsideration by the health carrier of | ||||||
15 | its adverse determination or final adverse determination | ||||||
16 | after the receipt of additional information from the | ||||||
17 | covered person or the covered person's authorized | ||||||
18 | representative; and | ||||||
19 | (9) any other information the Director may request or | ||||||
20 | require.
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21 | (Source: P.A. 96-857, eff. 7-1-10 .)
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22 | (215 ILCS 180/75)
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23 | Sec. 75. Disclosure requirements. | ||||||
24 | (a) Each health carrier shall include a description of the | ||||||
25 | external review procedures in, or attached to, the policy, |
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1 | certificate, membership booklet, and outline of coverage or | ||||||
2 | other evidence of coverage it provides to covered persons. | ||||||
3 | (b) The description required under subsection (a) of this | ||||||
4 | Section shall include a statement that informs the covered | ||||||
5 | person of the right of the covered person to file a request for | ||||||
6 | an external review of an adverse determination or final adverse | ||||||
7 | determination with the Director health carrier . The statement | ||||||
8 | shall explain that external review is available when the | ||||||
9 | adverse determination or final adverse determination involves | ||||||
10 | an issue of medical necessity, appropriateness, health care | ||||||
11 | setting, level of care, or effectiveness. The statement shall | ||||||
12 | include the toll-free telephone number and address of the | ||||||
13 | Office of Consumer Health Insurance within the Department of | ||||||
14 | Insurance.
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15 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
16 | (215 ILCS 180/80 new) | ||||||
17 | Sec. 80. Administration and enforcement. | ||||||
18 | (a) The Director of Insurance may adopt rules necessary to | ||||||
19 | implement the Department's responsibilities under this Act. | ||||||
20 | (b) The Director is authorized to make use of any of the | ||||||
21 | powers established under the Illinois Insurance Code to enforce | ||||||
22 | the laws of this State. This includes but is not limited to, | ||||||
23 | the Director's administrative authority to investigate, issue | ||||||
24 | subpoenas, conduct depositions and hearings, issue orders, | ||||||
25 | including, without limitation, orders pursuant to Article XII |
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| |||||||
1 | 1/2 and Section 401.1 of the Illinois Insurance Code, and | ||||||
2 | impose penalties.
| ||||||
3 | (215 ILCS 134/50 rep.) | ||||||
4 | Section 90-15. The Managed Care Reform and Patient Rights | ||||||
5 | Act is amended by repealing Section 50.
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6 | ARTICLE 99. | ||||||
7 | EFFECTIVE DATE
| ||||||
8 | Section 99-99. Effective date. This Act takes effect upon | ||||||
9 | becoming law.
|