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