Public Act 097-0574

HB0224 Enrolled LRB097 05693 RPM 45756 b

AN ACT concerning insurance.

Be it enacted by the People of the State of Illinois,

represented in the General Assembly:

Section 5. The Health Carrier External Review Act is

amended by changing Sections 10, 20, 25, 30, 35, 40, 55, 65,

and 75 and by adding Sections 42 and 80 as follows:

(215 ILCS 180/10)

Sec. 10. Definitions. For the purposes of this Act:

"Adverse determination" means:

(1) a determination by a health carrier or its designee

utilization review organization that, based upon the

information provided, a request for a benefit under the

health carrier's health benefit plan upon application of

any utilization review technique does not meet the health

carrier's requirements for medical necessity,

appropriateness, health care setting, level of care, or

effectiveness or is determined to be experimental or

investigational and the requested benefit is therefore

denied, reduced, or terminated or payment is not provided

or made, in whole or in part, for the benefit;

(2) the denial, reduction, or termination of or failure

to provide or make payment, in whole or in part, for a

benefit based on a determination by a health carrier or its

designee utilization review organization that a

preexisting condition was present before the effective

date of coverage; or

(3) a recission of coverage determination, which does

not include a cancellation or discontinuance of coverage

that is attributable to a failure to timely pay required

premiums or contributions towards the cost of coverage.

means a determination by a health carrier or its designee

utilization review organization that an admission,

availability of care, continued stay, or other health care

service that is a covered benefit has been reviewed and,

based upon the information provided, does not meet the

health carrier's requirements for medical necessity,

appropriateness, health care setting, level of care, or

effectiveness, and the requested service or payment for the

service is therefore denied, reduced, or terminated.

"Authorized representative" means:

(1) a person to whom a covered person has given express

written consent to represent the covered person for

purposes of this Law;

(2) a person authorized by law to provide substituted

consent for a covered person;

(3) a family member of the covered person or the

covered person's treating health care professional when

the covered person is unable to provide consent;

(4) a health care provider when the covered person's

health benefit plan requires that a request for a benefit

under the plan be initiated by the health care provider; or

(5) in the case of an urgent care request, a health

care provider with knowledge of the covered person's

medical condition.

(1) a person to whom a covered person has given express

written consent to represent the covered person in an

external review, including the covered person's health

care provider;

(2) a person authorized by law to provide substituted

consent for a covered person; or

(3) the covered person's health care provider when the

covered person is unable to provide consent.

"Best evidence" means evidence based on:

(1) randomized clinical trials;

(2) if randomized clinical trials are not available,

then cohort studies or case-control studies;

(3) if items (1) and (2) are not available, then

case-series; or

(4) if items (1), (2), and (3) are not available, then

expert opinion.

"Case-series" means an evaluation of a series of patients

with a particular outcome, without the use of a control group.

"Clinical review criteria" means the written screening

procedures, decision abstracts, clinical protocols, and

practice guidelines used by a health carrier to determine the

necessity and appropriateness of health care services.

"Cohort study" means a prospective evaluation of 2 groups

of patients with only one group of patients receiving specific

intervention.

"Concurrent review" means a review conducted during a

patient's stay or course of treatment in a facility, the office

of a health care professional, or other inpatient or outpatient

health care setting.

"Covered benefits" or "benefits" means those health care

services to which a covered person is entitled under the terms

of a health benefit plan.

"Covered person" means a policyholder, subscriber,

enrollee, or other individual participating in a health benefit

plan.

"Director" means the Director of the Department of

Insurance.

"Emergency medical condition" means a medical condition

manifesting itself by acute symptoms of sufficient severity,

including, but not limited to, severe pain, such that a prudent

layperson who possesses an average knowledge of health and

medicine could reasonably expect the absence of immediate

medical attention to result in:

(1) placing the health of the individual or, with

respect to a pregnant woman, the health of the woman or her

unborn child, in serious jeopardy;

(2) serious impairment to bodily functions; or

(3) serious dysfunction of any bodily organ or part.

"Emergency services" means health care items and services

furnished or required to evaluate and treat an emergency

medical condition.

"Evidence-based standard" means the conscientious,

explicit, and judicious use of the current best evidence based

on an overall systematic review of the research in making

decisions about the care of individual patients.

"Expert opinion" means a belief or an interpretation by

specialists with experience in a specific area about the

scientific evidence pertaining to a particular service,

intervention, or therapy.

"Facility" means an institution providing health care

services or a health care setting.

"Final adverse determination" means an adverse

determination involving a covered benefit that has been upheld

by a health carrier, or its designee utilization review

organization, at the completion of the health carrier's

internal grievance process procedures as set forth by the

Managed Care Reform and Patient Rights Act.

"Health benefit plan" means a policy, contract,

certificate, plan, or agreement offered or issued by a health

carrier to provide, deliver, arrange for, pay for, or reimburse

any of the costs of health care services.

"Health care provider" or "provider" means a physician,

hospital facility, or other health care practitioner licensed,

accredited, or certified to perform specified health care

services consistent with State law, responsible for

recommending health care services on behalf of a covered

person.

"Health care services" means services for the diagnosis,

prevention, treatment, cure, or relief of a health condition,

illness, injury, or disease.

"Health carrier" means an entity subject to the insurance

laws and regulations of this State, or subject to the

jurisdiction of the Director, that contracts or offers to

contract to provide, deliver, arrange for, pay for, or

reimburse any of the costs of health care services, including a

sickness and accident insurance company, a health maintenance

organization, or any other entity providing a plan of health

insurance, health benefits, or health care services. "Health

carrier" also means Limited Health Service Organizations

(LHSO) and Voluntary Health Service Plans.

"Health information" means information or data, whether

oral or recorded in any form or medium, and personal facts or

information about events or relationships that relate to:

(1) the past, present, or future physical, mental, or

behavioral health or condition of an individual or a member

of the individual's family;

(2) the provision of health care services to an

individual; or

(3) payment for the provision of health care services

to an individual.

"Independent review organization" means an entity that

conducts independent external reviews of adverse

determinations and final adverse determinations.

"Medical or scientific evidence" means evidence found in

the following sources:

(1) peer-reviewed scientific studies published in or

accepted for publication by medical journals that meet

nationally recognized requirements for scientific

manuscripts and that submit most of their published

articles for review by experts who are not part of the

editorial staff;

(2) peer-reviewed medical literature, including

literature relating to therapies reviewed and approved by a

qualified institutional review board, biomedical

compendia, and other medical literature that meet the

criteria of the National Institutes of Health's Library of

Medicine for indexing in Index Medicus (Medline) and

Elsevier Science Ltd. for indexing in Excerpta Medicus

(EMBASE);

(3) medical journals recognized by the Secretary of

Health and Human Services under Section 1861(t)(2) of the

federal Social Security Act;

(4) the following standard reference compendia:

(a) The American Hospital Formulary Service-Drug

Information;

(b) Drug Facts and Comparisons;

(c) The American Dental Association Accepted

Dental Therapeutics; and

(d) The United States Pharmacopoeia-Drug

Information;

(5) findings, studies, or research conducted by or

under the auspices of federal government agencies and

nationally recognized federal research institutes,

including:

(a) the federal Agency for Healthcare Research and

Quality;

(b) the National Institutes of Health;

(c) the National Cancer Institute;

(d) the National Academy of Sciences;

(e) the Centers for Medicare & Medicaid Services;

(f) the federal Food and Drug Administration; and

(g) any national board recognized by the National

Institutes of Health for the purpose of evaluating the

medical value of health care services; or

(6) any other medical or scientific evidence that is

comparable to the sources listed in items (1) through (5).

"Person" means an individual, a corporation, a

partnership, an association, a joint venture, a joint stock

company, a trust, an unincorporated organization, any similar

entity, or any combination of the foregoing.

"Prospective review" means a review conducted prior to an

admission or the provision of a health care service or a course

of treatment in accordance with a health carrier's requirement

that the health care service or course of treatment, in whole

or in part, be approved prior to its provision.

"Protected health information" means health information

(i) that identifies an individual who is the subject of the

information; or (ii) with respect to which there is a

reasonable basis to believe that the information could be used

to identify an individual.

"Randomized clinical trial" means a controlled prospective

study of patients that have been randomized into an

experimental group and a control group at the beginning of the

study with only the experimental group of patients receiving a

specific intervention, which includes study of the groups for

variables and anticipated outcomes over time.

"Retrospective review" means any review of a request for a

benefit that is not a concurrent or prospective review request.

"Retrospective review" does not include the review of a claim

that is limited to veracity of documentation or accuracy of

coding. means a review of medical necessity conducted after

services have been provided to a patient, but does not include

the review of a claim that is limited to an evaluation of

reimbursement levels, veracity of documentation, accuracy of

coding, or adjudication for payment.

"Utilization review" has the meaning provided by the

Managed Care Reform and Patient Rights Act.

"Utilization review organization" means a utilization

review program as defined in the Managed Care Reform and

Patient Rights Act.

(Source: P.A. 96-857, eff. 7-1-10.)

(215 ILCS 180/20)

Sec. 20. Notice of right to external review.

(a) At the same time the health carrier sends written

notice of a covered person's right to appeal a coverage

decision upon an adverse determination or a final adverse

determination as provided by the Managed Care Reform and

Patient Rights Act, a health carrier shall notify a covered

person, the covered person's authorized representative, if

any, and a covered person's health care provider in writing of

the covered person's right to request an external review as

provided by this Act. The written notice required shall include

the following, or substantially equivalent, language: "We have

denied your request for the provision of or payment for a

health care service or course of treatment. You have the right

to have our decision reviewed by an independent review

organization not associated with us if our decision involved

making a judgment as to the medical necessity, appropriateness,

health care setting, level of care, or effectiveness of the

health care service or treatment you requested by submitting a

written request for an external review to the Department of

Insurance, Office of Consumer Health Information, 320 West

Washington Street, 4th Floor, Springfield, Illinois, 62767."

us. Upon receipt of your request an independent review

organization registered with the Department of Insurance will

be assigned to review our decision.

(a-5) The Department may prescribe the form and content of

the notice required under this Section.

(b) This subsection (b) shall apply to an expedited review

prior to a final adverse determination. In addition to the

notice required in subsection (a), for the health carrier shall

include a notice related to an adverse determination, the

health carrier shall include a statement informing the covered

person of all of the following:

(1) If the covered person has a medical condition where

the timeframe for completion of (A) an expedited internal

review of an appeal a grievance involving an adverse

determination, (B) a final adverse determination as set

forth in the Managed Care Reform and Patient Rights Act, or

(C) a standard external review as established in this Act,

would seriously jeopardize the life or health of the

covered person or would jeopardize the covered person's

ability to regain maximum function, then the covered person

or the covered person's authorized representative may file

a request for an expedited external review.

(2) The covered person or the covered person's

authorized representative may file an appeal under the

health carrier's internal appeal process, but if the health

carrier has not issued a written decision to the covered

person or the covered person's authorized representative

30 days following the date the covered person or the

covered person's authorized representative files an appeal

of an adverse determination that involves a concurrent or

prospective review request or 60 days following the date

the covered person or the covered person's authorized

representative files an appeal of an adverse determination

that involves a retrospective review request with the

health carrier and the covered person or the covered

person's authorized representative has not requested or

agreed to a delay, then the covered person or the covered

person's authorized representative may file a request for

external review and shall be considered to have exhausted

the health carrier's internal appeal process for purposes

of this Act. The covered person or the covered person's

authorized representative may file a request for an

expedited external review at the same time the covered

person or the covered person's authorized representative

files a request for an expedited internal appeal involving

an adverse determination as set forth in the Managed Care

Reform and Patient Rights Act if the adverse determination

involves a denial of coverage based on a determination that

the recommended or requested health care service or

treatment is experimental or investigational and the

covered person's health care provider certifies in writing

that the recommended or requested health care service or

treatment that is the subject of the adverse determination

would be significantly less effective if not promptly

initiated. The independent review organization assigned to

conduct the expedited external review will determine

whether the covered person shall be required to complete

the expedited review of the grievance prior to conducting

the expedited external review.

(3) If the covered person or the covered person's

authorized representative filed a request for an expedited

internal review of an adverse determination and has not

received a decision on such request from the health carrier

within 48 hours, except to the extent the covered person or

the covered person's authorized representative requested

or agreed to a delay, then the covered person or the

covered person's authorized representative may file a

request for external review and shall be considered to have

exhausted the health carrier's internal appeal process for

the purposes of this Act.

(4) (3) If an adverse determination concerns a denial

of coverage based on a determination that the recommended

or requested health care service or treatment is

experimental or investigational and the covered person's

health care provider certifies in writing that the

recommended or requested health care service or treatment

that is the subject of the request would be significantly

less effective if not promptly initiated, then the covered

person or the covered person's authorized representative

may request an expedited external review at the same time

the covered person or the covered person's authorized

representative files a request for an expedited internal

appeal involving an adverse determination. The independent

review organization assigned to conduct the expedited

external review shall determine whether the covered person

is required to complete the expedited review of the appeal

prior to conducting the expedited external review.

(c) This subsection (c) shall apply to an expedited review

upon final adverse determination. In addition to the notice

required in subsection (a), for the health carrier shall

include a notice related to a final adverse determination, the

health carrier shall include a statement informing the covered

person of all of the following:

(1) if the covered person has a medical condition where

the timeframe for completion of a standard external review

would seriously jeopardize the life or health of the

covered person or would jeopardize the covered person's

ability to regain maximum function, then the covered person

or the covered person's authorized representative may file

a request for an expedited external review; or

(2) if a final adverse determination concerns an

admission, availability of care, continued stay, or health

care service for which the covered person received

emergency services, but has not been discharged from a

facility, then the covered person, or the covered person's

authorized representative, may request an expedited

external review; or

(3) if a final adverse determination concerns a denial

of coverage based on a determination that the recommended

or requested health care service or treatment is

experimental or investigational, and the covered person's

health care provider certifies in writing that the

recommended or requested health care service or treatment

that is the subject of the request would be significantly

less effective if not promptly initiated, then the covered

person or the covered person's authorized representative

may request an expedited external review.

(d) In addition to the information to be provided pursuant

to subsections (a), (b), and (c) of this Section, the health

carrier shall include a copy of the description of both the

required standard and expedited external review procedures.

The description shall highlight the external review procedures

that give the covered person or the covered person's authorized

representative the opportunity to submit additional

information, including any forms used to process an external

review.

(e) As part of any forms provided under subsection (d) of

this Section, the health carrier shall include an authorization

form, or other document approved by the Director, by which the

covered person, for purposes of conducting an external review

under this Act, authorizes the health carrier and the covered

person's treating health care provider to disclose protected

health information, including medical records, concerning the

covered person that is pertinent to the external review, as

provided in the Illinois Insurance Code.

(Source: P.A. 96-857, eff. 7-1-10.)

(215 ILCS 180/25)

Sec. 25. Request for external review. A covered person or

the covered person's authorized representative may make a

request for a standard external or expedited external review of

an adverse determination or final adverse determination.

Except as set forth in Sections 40 and 42 of this Act, all

requests for external review Requests under this Section shall

be made in writing to the Director directly to the health

carrier that made the adverse or final adverse determination.

All requests for external review shall be in writing except for

requests for expedited external reviews which may me made

orally. Health carriers must provide covered persons with forms

to request external reviews.

(Source: P.A. 96-857, eff. 7-1-10.)

(215 ILCS 180/30)

Sec. 30. Exhaustion of internal appeal grievance process.

(a) Except as provided in subsection (b) of this Section

20, a request for an external review shall not be made until

the covered person has exhausted the health carrier's internal

appeal grievance process as set forth in the Managed Care

Reform and Patient Rights Act.

(b) A covered person shall also be considered to have

exhausted the health carrier's internal appeal grievance

process for purposes of this Section if:

(1) the covered person or the covered person's

authorized representative has filed an appeal under the

health carrier's internal appeal process a request for an

internal review of an adverse determination pursuant to the

Managed Care Reform and Patient Rights Act and has not

received a written decision on the appeal 30 days following

the date the covered person or the covered person's

authorized representative files an appeal of an adverse

determination that involves a concurrent or prospective

review request or 60 days following the date the covered

person or the covered person's authorized representative

files an appeal of an adverse determination that involves a

retrospective review request request from the health

carrier within 15 days after receipt of the required

information but not more than 30 days after the request was

filed by the covered person or the covered person's

authorized representative, except to the extent the

covered person or the covered person's authorized

representative requested or agreed to a delay; however, a

covered person or the covered person's authorized

representative may not make a request for an external

review of an adverse determination involving a

retrospective review determination until the covered

person has exhausted the health carrier's internal

grievance process;

(2) the covered person or the covered person's

authorized representative filed a request for an expedited

internal review of an adverse determination pursuant to the

Managed Care Reform and Patient Rights Act and has not

received a decision on such request from the health carrier

within 48 hours, except to the extent the covered person or

the covered person's authorized representative requested

or agreed to a delay; or

(3) the health carrier agrees to waive the exhaustion

requirement; .

(4) the covered person has a medical condition in which

the timeframe for completion of (A) an expedited internal

review of an appeal involving an adverse determination, (B)

a final adverse determination, or (C) a standard external

review as established in this Act would seriously

jeopardize the life or health of the covered person or

would jeopardize the covered person's ability to regain

maximum function;

(5) an adverse determination concerns a denial of

coverage based on a determination that the recommended or

requested health care service or treatment is experimental

or investigational and the covered person's health care

provider certifies in writing that the recommended or

requested health care service or treatment that is the

subject of the request would be significantly less

effective if not promptly initiated; in such cases, the

covered person or the covered person's authorized

representative may request an expedited external review at

the same time the covered person or the covered person's

authorized representative files a request for an expedited

internal appeal involving an adverse determination; the

independent review organization assigned to conduct the

expedited external review shall determine whether the

covered person is required to complete the expedited review

of the appeal prior to conducting the expedited external

review; or

(6) the health carrier has failed to comply with

applicable State and federal law governing internal claims

and appeals procedures.

(Source: P.A. 96-857, eff. 7-1-10.)

(215 ILCS 180/35)

Sec. 35. Standard external review.

(a) Within 4 months after the date of receipt of a notice

of an adverse determination or final adverse determination, a

covered person or the covered person's authorized

representative may file a request for an external review with

the Director. Within one business day after the date of receipt

of a request for external review, the Director shall send a

copy of the request to the health carrier.

(b) Within 5 business days following the date of receipt of

the external review request, the health carrier shall complete

a preliminary review of the request to determine whether:

(1) the individual is or was a covered person in the

health benefit plan at the time the health care service was

requested or at the time the health care service was

provided;

(2) the health care service that is the subject of the

adverse determination or the final adverse determination

is a covered service under the covered person's health

benefit plan, but the health carrier has determined that

the health care service is not covered because it does not

meet the health carrier's requirements for medical

necessity, appropriateness, health care setting, level of

care, or effectiveness;

(3) the covered person has exhausted the health

carrier's internal appeal grievance process unless the

covered person is not required to exhaust the health

carrier's internal appeal process pursuant to as set forth

in this Act;

(4) (blank); and for appeals relating to a

determination based on treatment being experimental or

investigational, the requested health care service or

treatment that is the subject of the adverse determination

or final adverse determination is a covered benefit under

the covered person's health benefit plan except for the

health carrier's determination that the service or

treatment is experimental or investigational for a

particular medical condition and is not explicitly listed

as an excluded benefit under the covered person's health

benefit plan with the health carrier and that the covered

person's health care provider, who ordered or provided the

services in question and who is licensed under the Medical

Practice Act of 1987, has certified that one of the

following situations is applicable:

(A) standard health care services or treatments

have not been effective in improving the condition of

the covered person;

(B) standard health care services or treatments

are not medically appropriate for the covered person;

(C) there is no available standard health care

service or treatment covered by the health carrier that

is more beneficial than the recommended or requested

health care service or treatment;

(D) the health care service or treatment is likely

to be more beneficial to the covered person, in the

health care provider's opinion, than any available

standard health care services or treatments; or

(E) that scientifically valid studies using

accepted protocols demonstrate that the health care

service or treatment requested is likely to be more

beneficial to the covered person than any available

standard health care services or treatments; and

(5) the covered person has provided all the information

and forms required to process an external review, as

specified in this Act.

(c) Within one business day after completion of the

preliminary review, the health carrier shall notify the

Director and covered person and, if applicable, the covered

person's authorized representative in writing whether the

request is complete and eligible for external review. If the

request:

(1) is not complete, the health carrier shall inform

the Director and covered person and, if applicable, the

covered person's authorized representative in writing and

include in the notice what information or materials are

required by this Act to make the request complete; or

(2) is not eligible for external review, the health

carrier shall inform the Director and covered person and,

if applicable, the covered person's authorized

representative in writing and include in the notice the

reasons for its ineligibility.

The Department may specify the form for the health

carrier's notice of initial determination under this

subsection (c) and any supporting information to be included in

the notice.

The notice of initial determination of ineligibility shall

include a statement informing the covered person and, if

applicable, the covered person's authorized representative

that a health carrier's initial determination that the external

review request is ineligible for review may be appealed to the

Director by filing a complaint with the Director.

Notwithstanding a health carrier's initial determination

that the request is ineligible for external review, the

Director may determine that a request is eligible for external

review and require that it be referred for external review. In

making such determination, the Director's decision shall be in

accordance with the terms of the covered person's health

benefit plan, unless such terms are inconsistent with

applicable law, and shall be subject to all applicable

provisions of this Act.

(d) Whenever the Director receives notice that a request is

eligible for external review following the preliminary review

conducted pursuant to this Section the health carrier shall,

within one 5 business day after the date of receipt of the

notice, the Director shall days:

(1) assign an independent review organization from the

list of approved independent review organizations compiled

and maintained by the Director pursuant to this Act and

notify the health carrier of the name of the assigned

independent review organization; and

(2) notify in writing the covered person and, if

applicable, the covered person's authorized representative

of the request's eligibility and acceptance for external

review and the name of the independent review organization.

The Director health carrier shall include in the notice

provided to the covered person and, if applicable, the covered

person's authorized representative a statement that the

covered person or the covered person's authorized

representative may, within 5 business days following the date

of receipt of the notice provided pursuant to item (2) of this

subsection (d), submit in writing to the assigned independent

review organization additional information that the

independent review organization shall consider when conducting

the external review. The independent review organization is not

required to, but may, accept and consider additional

information submitted after 5 business days.

(e) The assignment by the Director of an approved

independent review organization to conduct an external review

in accordance with this Section shall be done on a random basis

among those independent review organizations approved by the

Director pursuant to this Act. The assignment of an approved

independent review organization to conduct an external review

in accordance with this Section shall be made from those

approved independent review organizations qualified to conduct

external review as required by Sections 50 and 55 of this Act.

(f) Within Upon assignment of an independent review

organization, the health carrier or its designee utilization

review organization shall, within 5 business days after the

date of receipt of the notice provided pursuant to item (1) of

subsection (d) of this Section, the health carrier or its

designee utilization review organization shall provide to the

assigned independent review organization the documents and any

information considered in making the adverse determination or

final adverse determination; in such cases, the following

provisions shall apply:

(1) Except as provided in item (2) of this subsection

(f), failure by the health carrier or its utilization

review organization to provide the documents and

information within the specified time frame shall not delay

the conduct of the external review.

(2) If the health carrier or its utilization review

organization fails to provide the documents and

information within the specified time frame, the assigned

independent review organization may terminate the external

review and make a decision to reverse the adverse

determination or final adverse determination.

(3) Within one business day after making the decision

to terminate the external review and make a decision to

reverse the adverse determination or final adverse

determination under item (2) of this subsection (f), the

independent review organization shall notify the Director,

the health carrier, the covered person and, if applicable,

the covered person's authorized representative, of its

decision to reverse the adverse determination.

(g) Upon receipt of the information from the health carrier

or its utilization review organization, the assigned

independent review organization shall review all of the

information and documents and any other information submitted

in writing to the independent review organization by the

covered person and the covered person's authorized

representative.

(h) Upon receipt of any information submitted by the

covered person or the covered person's authorized

representative, the independent review organization shall

forward the information to the health carrier within 1 business

day.

(1) Upon receipt of the information, if any, the health

carrier may reconsider its adverse determination or final

adverse determination that is the subject of the external

review.

(2) Reconsideration by the health carrier of its

adverse determination or final adverse determination shall

not delay or terminate the external review.

(3) The external review may only be terminated if the

health carrier decides, upon completion of its

reconsideration, to reverse its adverse determination or

final adverse determination and provide coverage or

payment for the health care service that is the subject of

the adverse determination or final adverse determination.

In such cases, the following provisions shall apply:

(A) Within one business day after making the

decision to reverse its adverse determination or final

adverse determination, the health carrier shall notify

the Director, the covered person and, if applicable,

the covered person's authorized representative, and

the assigned independent review organization in

writing of its decision.

(B) Upon notice from the health carrier that the

health carrier has made a decision to reverse its

adverse determination or final adverse determination,

the assigned independent review organization shall

terminate the external review.

(i) In addition to the documents and information provided

by the health carrier or its utilization review organization

and the covered person and the covered person's authorized

representative, if any, the independent review organization,

to the extent the information or documents are available and

the independent review organization considers them

appropriate, shall consider the following in reaching a

decision:

(1) the covered person's pertinent medical records;

(2) the covered person's health care provider's

recommendation;

(3) consulting reports from appropriate health care

providers and other documents submitted by the health

carrier or its designee utilization review organization,

the covered person, the covered person's authorized

representative, or the covered person's treating provider;

(4) the terms of coverage under the covered person's

health benefit plan with the health carrier to ensure that

the independent review organization's decision is not

contrary to the terms of coverage under the covered

person's health benefit plan with the health carrier,

unless the terms are inconsistent with applicable law;

(5) the most appropriate practice guidelines, which

shall include applicable evidence-based standards and may

include any other practice guidelines developed by the

federal government, national or professional medical

societies, boards, and associations;

(6) any applicable clinical review criteria developed

and used by the health carrier or its designee utilization

review organization; and

(7) the opinion of the independent review

organization's clinical reviewer or reviewers after

considering items (1) through (6) of this subsection (i) to

the extent the information or documents are available and

the clinical reviewer or reviewers considers the

information or documents appropriate; and

(8) (blank). for a denial of coverage based on a

determination that the health care service or treatment

recommended or requested is experimental or

investigational, whether and to what extent:

(A) the recommended or requested health care

service or treatment has been approved by the federal

Food and Drug Administration, if applicable, for the

condition;

(B) medical or scientific evidence or

evidence-based standards demonstrate that the expected

benefits of the recommended or requested health care

service or treatment is more likely than not to be

beneficial to the covered person than any available

standard health care service or treatment and the

adverse risks of the recommended or requested health

care service or treatment would not be substantially

increased over those of available standard health care

services or treatments; or

(C) the terms of coverage under the covered

person's health benefit plan with the health carrier to

ensure that the health care service or treatment that

is the subject of the opinion is experimental or

investigational would otherwise be covered under the

terms of coverage of the covered person's health

benefit plan with the health carrier.

(j) Within 5 days after the date of receipt of all

necessary information, but in no event more than 45 days after

the date of receipt of the request for an external review, the

assigned independent review organization shall provide written

notice of its decision to uphold or reverse the adverse

determination or the final adverse determination to the

Director, the health carrier, the covered person, and, if

applicable, the covered person's authorized representative. In

reaching a decision, the assigned independent review

organization is not bound by any claim determinations reached

prior to the submission of information to the independent

review organization. In such cases, the following provisions

shall apply:

(1) The independent review organization shall include

in the notice:

(A) a general description of the reason for the

request for external review;

(B) the date the independent review organization

received the assignment from the Director health

carrier to conduct the external review;

(C) the time period during which the external

review was conducted;

(D) references to the evidence or documentation,

including the evidence-based standards, considered in

reaching its decision;

(E) the date of its decision; and

(F) the principal reason or reasons for its

decision, including what applicable, if any,

evidence-based standards that were a basis for its

decision; and .

(G) the rationale for its decision.

(2) (Blank). For reviews of experimental or

investigational treatments, the notice shall include the

following information:

(A) a description of the covered person's medical

condition;

(B) a description of the indicators relevant to

whether there is sufficient evidence to demonstrate

that the recommended or requested health care service

or treatment is more likely than not to be more

beneficial to the covered person than any available

standard health care services or treatments and the

adverse risks of the recommended or requested health

care service or treatment would not be substantially

increased over those of available standard health care

services or treatments;

(C) a description and analysis of any medical or

scientific evidence considered in reaching the

opinion;

(D) a description and analysis of any

evidence-based standards;

(E) whether the recommended or requested health

care service or treatment has been approved by the

federal Food and Drug Administration, for the

condition;

(F) whether medical or scientific evidence or

evidence-based standards demonstrate that the expected

benefits of the recommended or requested health care

service or treatment is more likely than not to be more

beneficial to the covered person than any available

standard health care service or treatment and the

adverse risks of the recommended or requested health

care service or treatment would not be substantially

increased over those of available standard health care

services or treatments; and

(G) the written opinion of the clinical reviewer,

including the reviewer's recommendation as to whether

the recommended or requested health care service or

treatment should be covered and the rationale for the

reviewer's recommendation.

(3) (Blank). In reaching a decision, the assigned

independent review organization is not bound by any

decisions or conclusions reached during the health

carrier's utilization review process or the health

carrier's internal grievance or appeals process.

(4) Upon receipt of a notice of a decision reversing

the adverse determination or final adverse determination,

the health carrier immediately shall approve the coverage

that was the subject of the adverse determination or final

adverse determination.

(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)

(215 ILCS 180/40)

Sec. 40. Expedited external review.

(a) A covered person or a covered person's authorized

representative may file a request for an expedited external

review with the Director health carrier either orally or in

writing:

(1) immediately after the date of receipt of a notice

prior to a final adverse determination as provided by

subsection (b) of Section 20 of this Act;

(2) immediately after the date of receipt of a notice

upon a final adverse determination as provided by

subsection (c) of Section 20 of this Act; or

(3) if a health carrier fails to provide a decision on

request for an expedited internal appeal within 48 hours as

provided by item (2) of Section 30 of this Act.

(b) Upon receipt of a request for an expedited external

review, the Director shall immediately send a copy of the

request to the health carrier. Immediately upon receipt of the

request for an expedited external review as provided under

subsections (b) and (c) of Section 20, the health carrier shall

determine whether the request meets the reviewability

requirements set forth in items (1), (2), and (4) of subsection

(b) of Section 35. In such cases, the following provisions

shall apply:

(1) The health carrier shall immediately notify the

Director, the covered person, and, if applicable, the

covered person's authorized representative of its

eligibility determination.

(2) The notice of initial determination shall include a

statement informing the covered person and, if applicable,

the covered person's authorized representative that a

health carrier's initial determination that an external

review request is ineligible for review may be appealed to

the Director.

(3) The Director may determine that a request is

eligible for expedited external review notwithstanding a

health carrier's initial determination that the request is

ineligible and require that it be referred for external

review.

(4) In making a determination under item (3) of this

subsection (b), the Director's decision shall be made in

accordance with the terms of the covered person's health

benefit plan, unless such terms are inconsistent with

applicable law, and shall be subject to all applicable

provisions of this Act.

(5) The Director may specify the form for the health

carrier's notice of initial determination under this

subsection (b) and any supporting information to be

included in the notice.

(c) Upon receipt of the notice that the request meets the

reviewability requirements, determining that a request meets

the requirements of subsections (b) and (c) of Section 20, the

Director health carrier shall immediately assign an

independent review organization from the list of approved

independent review organizations compiled and maintained by

the Director to conduct the expedited review. In such cases,

the following provisions shall apply:

(1) The assignment of an approved independent review

organization to conduct an external review in accordance

with this Section shall be made from those approved

independent review organizations qualified to conduct

external review as required by Sections 50 and 55 of this

Act.

(2) The Director shall immediately notify the health

carrier of the name of the assigned independent review

organization. Immediately upon receipt from the Director

of the name of the independent review organization assigned

to conduct the external review assigning an independent

review organization to perform an expedited external

review, but in no case more than 24 hours after receiving

such notice assigning the independent review organization,

the health carrier or its designee utilization review

organization shall provide or transmit all necessary

documents and information considered in making the adverse

determination or final adverse determination to the

assigned independent review organization electronically or

by telephone or facsimile or any other available

expeditious method.

(3) If the health carrier or its utilization review

organization fails to provide the documents and

information within the specified timeframe, the assigned

independent review organization may terminate the external

review and make a decision to reverse the adverse

determination or final adverse determination.

(4) Within one business day after making the decision

to terminate the external review and make a decision to

reverse the adverse determination or final adverse

determination under item (3) of this subsection (c), the

independent review organization shall notify the Director,

the health carrier, the covered person, and, if applicable,

the covered person's authorized representative of its

decision to reverse the adverse determination or final

adverse determination.

(d) In addition to the documents and information provided

by the health carrier or its utilization review organization

and any documents and information provided by the covered

person and the covered person's authorized representative, the

independent review organization, to the extent the information

or documents are available and the independent review

organization considers them appropriate, shall consider

information as required by subsection (i) of Section 35 of this

Act in reaching a decision.

(e) As expeditiously as the covered person's medical

condition or circumstances requires, but in no event more than

72 hours after the date of receipt of the request for an

expedited external review 2 business days after the receipt of

all pertinent information, the assigned independent review

organization shall:

(1) make a decision to uphold or reverse the final

adverse determination; and

(2) notify the Director, the health carrier, the

covered person, the covered person's health care provider,

and, if applicable, the covered person's authorized

representative, of the decision.

(f) In reaching a decision, the assigned independent review

organization is not bound by any decisions or conclusions

reached during the health carrier's utilization review process

or the health carrier's internal appeal grievance process as

set forth in the Managed Care Reform and Patient Rights Act.

(g) Upon receipt of notice of a decision reversing the

adverse determination or final adverse determination, the

health carrier shall immediately approve the coverage that was

the subject of the adverse determination or final adverse

determination.

(h) If the notice provided pursuant to subsection (e) of

this Section was not in writing, then within Within 48 hours

after the date of providing that the notice required in item

(2) of subsection (e), the assigned independent review

organization shall provide written confirmation of the

decision to the Director, the health carrier, the covered

person, and, if applicable, the covered person's authorized

representative including the information set forth in

subsection (j) of Section 35 of this Act as applicable.

(i) An expedited external review may not be provided for

retrospective adverse or final adverse determinations.

(j) The assignment by the Director of an approved

independent review organization to conduct an external review

in accordance with this Section shall be done on a random basis

among those independent review organizations approved by the

Director pursuant to this Act.

(Source: P.A. 96-857, eff. 7-1-10; revised 9-16-10.)

(215 ILCS 180/42 new)

Sec. 42. External review of experimental or

investigational treatment adverse determinations.

(a) Within 4 months after the date of receipt of a notice

of an adverse determination or final adverse determination that

involves a denial of coverage based on a determination that the

health care service or treatment recommended or requested is

experimental or investigational, a covered person or the

covered person's authorized representative may file a request

for an external review with the Director.

(b) The following provisions apply to cases concerning

expedited external reviews:

(1) A covered person or the covered person's authorized

representative may make an oral request for an expedited

external review of the adverse determination or final

adverse determination pursuant to subsection (a) of this

Section if the covered person's treating physician

certifies, in writing, that the recommended or requested

health care service or treatment that is the subject of the

request would be significantly less effective if not

promptly initiated.

(2) Upon receipt of a request for an expedited external

review, the Director shall immediately notify the health

carrier.

(3) The following provisions apply concerning notice:

(A) Upon notice of the request for an expedited

external review, the health carrier shall immediately

determine whether the request meets the reviewability

requirements of subsection (d) of this Section. The

health carrier shall immediately notify the Director

and the covered person and, if applicable, the covered

person's authorized representative of its eligibility

determination.

(B) The Director may specify the form for the

health carrier's notice of initial determination under

subdivision (A) of this item (3) and any supporting

information to be included in the notice.

(C) The notice of initial determination under

subdivision (A) of this item (3) shall include a

statement informing the covered person and, if

applicable, the covered person's authorized

representative that a health carrier's initial

determination that the external review request is

ineligible for review may be appealed to the Director.

(4) The following provisions apply concerning the

Director's determination:

(A) The Director may determine that a request is

eligible for external review under subsection (d) of

this Section notwithstanding a health carrier's

initial determination that the request is ineligible

and require that it be referred for external review.

(B) In making a determination under subdivision

(A) of this item (4), the Director's decision shall be

made in accordance with the terms of the covered

person's health benefit plan, unless such terms are

inconsistent with applicable law, and shall be subject

to all applicable provisions of this Act.

(5) Upon receipt of the notice that the expedited

external review request meets the reviewability

requirements of subsection (d) of this Section, the

Director shall immediately assign an independent review

organization to review the expedited request from the list

of approved independent review organizations compiled and

maintained by the Director and notify the health carrier of

the name of the assigned independent review organization.

(6) At the time the health carrier receives the notice

of the assigned independent review organization, the

health carrier or its designee utilization review

organization shall provide or transmit all necessary

documents and information considered in making the adverse

determination or final adverse determination to the

assigned independent review organization electronically or

by telephone or facsimile or any other available

expeditious method.

(c) Except for a request for an expedited external review

made pursuant to subsection (b) of this Section, within one

business day after the date of receipt of a request for

external review, the Director shall send a copy of the request

to the health carrier.

(d) Within 5 business days following the date of receipt of

the external review request, the health carrier shall complete

a preliminary review of the request to determine whether:

(1) the individual is or was a covered person in the

health benefit plan at the time the health care service was

recommended or requested or, in the case of a retrospective

review, at the time the health care service was provided;

(2) the recommended or requested health care service or

treatment that is the subject of the adverse determination

or final adverse determination is a covered benefit under

the covered person's health benefit plan except for the

health carrier's determination that the service or

treatment is experimental or investigational for a

particular medical condition and is not explicitly listed

as an excluded benefit under the covered person's health

benefit plan with the health carrier;

(3) the covered person's health care provider has

certified that one of the following situations is

applicable:

(A) standard health care services or treatments

have not been effective in improving the condition of

the covered person;

(B) standard health care services or treatments

are not medically appropriate for the covered person;

or

(C) there is no available standard health care

service or treatment covered by the health carrier that

is more beneficial than the recommended or requested

health care service or treatment;

(4) the covered person's health care provider:

(A) has recommended a health care service or

treatment that the physician certifies, in writing, is

likely to be more beneficial to the covered person, in

the physician's opinion, than any available standard

health care services or treatments; or

(B) who is a licensed, board certified or board

eligible physician qualified to practice in the area of

medicine appropriate to treat the covered person's

condition, has certified in writing that

scientifically valid studies using accepted protocols

demonstrate that the health care service or treatment

requested by the covered person that is the subject of

the adverse determination or final adverse

determination is likely to be more beneficial to the

covered person than any available standard health care

services or treatments;

(5) the covered person has exhausted the health

carrier's internal appeal process, unless the covered

person is not required to exhaust the health carrier's

internal appeal process pursuant to Section 30 of this Act;

and

(6) the covered person has provided all the information

and forms required to process an external review, as

specified in this Act.

(e) The following provisions apply concerning requests:

(1) Within one business day after completion of the

preliminary review, the health carrier shall notify the

Director and covered person and, if applicable, the covered

person's authorized representative in writing whether the

request is complete and eligible for external review.

(2) If the request:

(A) is not complete, then the health carrier shall

inform the Director and the covered person and, if

applicable, the covered person's authorized

representative in writing and include in the notice

what information or materials are required by this Act

to make the request complete; or

(B) is not eligible for external review, then the

health carrier shall inform the Director and the

covered person and, if applicable, the covered

person's authorized representative in writing and

include in the notice the reasons for its

ineligibility.

(3) The Department may specify the form for the health

carrier's notice of initial determination under this

subsection (e) and any supporting information to be

included in the notice.

(4) The notice of initial determination of

ineligibility shall include a statement informing the

covered person and, if applicable, the covered person's

authorized representative that a health carrier's initial

determination that the external review request is

ineligible for review may be appealed to the Director by

filing a complaint with the Director.

(5) Notwithstanding a health carrier's initial

determination that the request is ineligible for external

review, the Director may determine that a request is

eligible for external review and require that it be

referred for external review. In making such

determination, the Director's decision shall be in

accordance with the terms of the covered person's health

benefit plan, unless such terms are inconsistent with

applicable law, and shall be subject to all applicable

provisions of this Act.

(f) Whenever a request for external review is determined

eligible for external review, the health carrier shall notify

the Director and the covered person and, if applicable, the

covered person's authorized representative.

(g) Whenever the Director receives notice that a request is

eligible for external review following the preliminary review

conducted pursuant to this Section, within one business day

after the date of receipt of the notice, the Director shall:

(1) assign an independent review organization from the

list of approved independent review organizations compiled

and maintained by the Director pursuant to this Act and

notify the health carrier of the name of the assigned

independent review organization; and

(2) notify in writing the covered person and, if

applicable, the covered person's authorized representative

of the request's eligibility and acceptance for external

review and the name of the independent review organization.

The Director shall include in the notice provided to the

covered person and, if applicable, the covered person's

authorized representative a statement that the covered person

or the covered person's authorized representative may, within 5

business days following the date of receipt of the notice

provided pursuant to item (2) of this subsection (g), submit in

writing to the assigned independent review organization

additional information that the independent review

organization shall consider when conducting the external

review. The independent review organization is not required to,

but may, accept and consider additional information submitted

after 5 business days.

(h) The following provisions apply concerning assignments

and clinical reviews:

(1) Within one business day after the receipt of the

notice of assignment to conduct the external review

pursuant to subsection (g) of this Section, the assigned

independent review organization shall select one or more

clinical reviewers, as it determines is appropriate,

pursuant to item (2) of this subsection (h) to conduct the

external review.

(2) The provisions of this item (2) apply concerning

the selection of reviewers:

(A) In selecting clinical reviewers pursuant to

item (1) of this subsection (h), the assigned

independent review organization shall select

physicians or other health care professionals who meet

the minimum qualifications described in Section 55 of

this Act and, through clinical experience in the past 3

years, are experts in the treatment of the covered

person's condition and knowledgeable about the

recommended or requested health care service or

treatment.

(B) Neither the covered person, the covered

person's authorized representative, if applicable, nor

the health carrier shall choose or control the choice

of the physicians or other health care professionals to

be selected to conduct the external review.

(3) In accordance with subsection (l) of this Section,

each clinical reviewer shall provide a written opinion to

the assigned independent review organization on whether

the recommended or requested health care service or

treatment should be covered.

(4) In reaching an opinion, clinical reviewers are not

bound by any decisions or conclusions reached during the

health carrier's utilization review process or the health

carrier's internal appeal process.

(i) Within 5 business days after the date of receipt of the

notice provided pursuant to subsection (g) of this Section, the

health carrier or its designee utilization review organization

shall provide to the assigned independent review organization

the documents and any information considered in making the

adverse determination or final adverse determination; in such

cases, the following provisions shall apply:

(1) Except as provided in item (2) of this subsection

(i), failure by the health carrier or its utilization

review organization to provide the documents and

information within the specified time frame shall not delay

the conduct of the external review.

(2) If the health carrier or its utilization review

organization fails to provide the documents and

information within the specified time frame, the assigned

independent review organization may terminate the external

review and make a decision to reverse the adverse

determination or final adverse determination.

(3) Immediately upon making the decision to terminate

the external review and make a decision to reverse the

adverse determination or final adverse determination under

item (2) of this subsection (i), the independent review

organization shall notify the Director, the health

carrier, the covered person, and, if applicable, the

covered person's authorized representative of its decision

to reverse the adverse determination.

(j) Upon receipt of the information from the health carrier

or its utilization review organization, each clinical reviewer

selected pursuant to subsection (h) of this Section shall

review all of the information and documents and any other

information submitted in writing to the independent review

organization by the covered person and the covered person's

authorized representative.

(k) Upon receipt of any information submitted by the

covered person or the covered person's authorized

representative, the independent review organization shall

forward the information to the health carrier within one

business day. In such cases, the following provisions shall

apply:

(1) Upon receipt of the information, if any, the health

carrier may reconsider its adverse determination or final

adverse determination that is the subject of the external

review.

(2) Reconsideration by the health carrier of its

adverse determination or final adverse determination shall

not delay or terminate the external review.

(3) The external review may be terminated only if the

health carrier decides, upon completion of its

reconsideration, to reverse its adverse determination or

final adverse determination and provide coverage or

payment for the health care service that is the subject of

the adverse determination or final adverse determination.

In such cases, the following provisions shall apply:

(A) Immediately upon making its decision to

reverse its adverse determination or final adverse

determination, the health carrier shall notify the

Director, the covered person and, if applicable, the

covered person's authorized representative, and the

assigned independent review organization in writing of

its decision.

(B) Upon notice from the health carrier that the

health carrier has made a decision to reverse its

adverse determination or final adverse determination,

the assigned independent review organization shall

terminate the external review.

(l) The following provisions apply concerning clinical

review opinions:

(1) Except as provided in item (3) of this subsection

(l), within 20 days after being selected in accordance with

subsection (h) of this Section to conduct the external

review, each clinical reviewer shall provide an opinion to

the assigned independent review organization on whether

the recommended or requested health care service or

treatment should be covered.

(2) Except for an opinion provided pursuant to item (3)

of this subsection (l), each clinical reviewer's opinion

shall be in writing and include the following information:

(A) a description of the covered person's medical

condition;

(B) a description of the indicators relevant to

determining whether there is sufficient evidence to

demonstrate that the recommended or requested health

care service or treatment is more likely than not to be

beneficial to the covered person than any available

standard health care services or treatments and the

adverse risks of the recommended or requested health

care service or treatment would not be substantially

increased over those of available standard health care

services or treatments;

(C) a description and analysis of any medical or

scientific evidence considered in reaching the

opinion;

(D) a description and analysis of any

evidence-based standard; and

(E) information on whether the reviewer's

rationale for the opinion is based on clause (A) or (B)

of item (5) of subsection (m) of this Section.

(3) The provisions of this item (3) apply concerning

the timing of opinions:

(A) For an expedited external review, each

clinical reviewer shall provide an opinion orally or in

writing to the assigned independent review

organization as expeditiously as the covered person's

medical condition or circumstances requires, but in no

event more than 5 calendar days after being selected in

accordance with subsection (h) of this Section.

(B) If the opinion provided pursuant to

subdivision (A) of this item (3) was not in writing,

then within 48 hours following the date the opinion was

provided, the clinical reviewer shall provide written

confirmation of the opinion to the assigned

independent review organization and include the

information required under item (2) of this subsection

(l).

(m) In addition to the documents and information provided

by the health carrier or its utilization review organization

and the covered person and the covered person's authorized

representative, if any, each clinical reviewer selected

pursuant to subsection (h) of this Section, to the extent the

information or documents are available and the clinical

reviewer considers appropriate, shall consider the following

in reaching a decision:

(1) the covered person's pertinent medical records;

(2) the covered person's health care provider's

recommendation;

(3) consulting reports from appropriate health care

providers and other documents submitted by the health

carrier or its designee utilization review organization,

the covered person, the covered person's authorized

representative, or the covered person's treating physician

or health care professional;

(4) the terms of coverage under the covered person's

health benefit plan with the health carrier to ensure that,

but for the health carrier's determination that the

recommended or requested health care service or treatment

that is the subject of the opinion is experimental or

investigational, the reviewer's opinion is not contrary to

the terms of coverage under the covered person's health

benefit plan with the health carrier; and

(5) whether (A) the recommended or requested health

care service or treatment has been approved by the federal

Food and Drug Administration, if applicable, for the

condition or (B) medical or scientific evidence or

evidence-based standards demonstrate that the expected

benefits of the recommended or requested health care

service or treatment is more likely than not to be

beneficial to the covered person than any available

standard health care service or treatment and the adverse

risks of the recommended or requested health care service

or treatment would not be substantially increased over

those of available standard health care services or

treatments.

(n) The following provisions apply concerning decisions,

notices, and recommendations:

(1) The provisions of this item (1) apply concerning

decisions and notices:

(A) Except as provided in subdivision (B) of this

item (1), within 20 days after the date it receives the

opinion of each clinical reviewer, the assigned

independent review organization, in accordance with

item (2) of this subsection (n), shall make a decision

and provide written notice of the decision to the

Director, the health carrier, the covered person, and

the covered person's authorized representative, if

applicable.

(B) For an expedited external review, within 48

hours after the date it receives the opinion of each

clinical reviewer, the assigned independent review

organization, in accordance with item (2) of this

subsection (n), shall make a decision and provide

notice of the decision orally or in writing to the

Director, the health carrier, the covered person, and

the covered person's authorized representative, if

applicable. If such notice is not in writing, within 48

hours after the date of providing that notice, the

assigned independent review organization shall provide

written confirmation of the decision to the Director,

the health carrier, the covered person, and the covered

person's authorized representative, if applicable.

(2) The provisions of this item (2) apply concerning

recommendations:

(A) If a majority of the clinical reviewers

recommend that the recommended or requested health

care service or treatment should be covered, then the

independent review organization shall make a decision

to reverse the health carrier's adverse determination

or final adverse determination.

(B) If a majority of the clinical reviewers

recommend that the recommended or requested health

care service or treatment should not be covered, the

independent review organization shall make a decision

to uphold the health carrier's adverse determination

or final adverse determination.

(C) The provisions of this subdivision (C) apply to

cases in which the clinical reviewers are evenly split:

(i) If the clinical reviewers are evenly split

as to whether the recommended or requested health

care service or treatment should be covered, then

the independent review organization shall obtain

the opinion of an additional clinical reviewer in

order for the independent review organization to

make a decision based on the opinions of a majority

of the clinical reviewers pursuant to subdivision

(A) or (B) of this item (2).

(ii) The additional clinical reviewer selected

under clause (i) of this subdivision (C) shall use

the same information to reach an opinion as the

clinical reviewers who have already submitted

their opinions.

(iii) The selection of the additional clinical

reviewer under this subdivision (C) shall not

extend the time within which the assigned

independent review organization is required to

make a decision based on the opinions of the

clinical reviewers.

(o) The independent review organization shall include in

the notice provided pursuant to subsection (n) of this Section:

(1) a general description of the reason for the request

for external review;

(2) the written opinion of each clinical reviewer,

including the recommendation of each clinical reviewer as

to whether the recommended or requested health care service

or treatment should be covered and the rationale for the

reviewer's recommendation;

(3) the date the independent review organization

received the assignment from the Director to conduct the

external review;

(4) the time period during which the external review

was conducted;

(5) the date of its decision;

(6) the principal reason or reasons for its decision;

and

(7) the rationale for its decision.

(p) Upon receipt of a notice of a decision reversing the

adverse determination or final adverse determination, the

health carrier shall immediately approve the coverage that was

the subject of the adverse determination or final adverse

determination.

(q) The assignment by the Director of an approved

independent review organization to conduct an external review

in accordance with this Section shall be done on a random basis

among those independent review organizations approved by the

Director pursuant to this Act.

(215 ILCS 180/55)

Sec. 55. Minimum qualifications for independent review

organizations.

(a) To be approved to conduct external reviews, an

independent review organization shall have and maintain

written policies and procedures that govern all aspects of both

the standard external review process and the expedited external

review process set forth in this Act that include, at a

minimum:

(1) a quality assurance mechanism that ensures that:

(A) external reviews are conducted within the

specified timeframes and required notices are provided

in a timely manner;

(B) selection of qualified and impartial clinical

reviewers to conduct external reviews on behalf of the

independent review organization and suitable matching

of reviewers to specific cases and that the independent

review organization employs or contracts with an

adequate number of clinical reviewers to meet this

objective;

(C) for adverse determinations involving

experimental or investigational treatments, in

assigning clinical reviewers, the independent review

organization selects physicians or other health care

professionals who, through clinical experience in the

past 3 years, are experts in the treatment of the

covered person's condition and knowledgeable about the

recommended or requested health care service or

treatment;

(D) the health carrier, the covered person, and the

covered person's authorized representative shall not

choose or control the choice of the physicians or other

health care professionals to be selected to conduct the

external review;

(E) confidentiality of medical and treatment

records and clinical review criteria; and

(F) any person employed by or under contract with

the independent review organization adheres to the

requirements of this Act;

(2) a toll-free telephone service operating on a

24-hour-day, 7-day-a-week basis that accepts, receives,

and records information related to external reviews and

provides appropriate instructions; and

(3) an agreement to maintain and provide to the

Director the information set out in Section 70 of this Act.

(b) All clinical reviewers assigned by an independent

review organization to conduct external reviews shall be

physicians or other appropriate health care providers who meet

the following minimum qualifications:

(1) be an expert in the treatment of the covered

person's medical condition that is the subject of the

external review;

(2) be knowledgeable about the recommended health care

service or treatment through recent or current actual

clinical experience treating patients with the same or

similar medical condition of the covered person;

(3) hold a non-restricted license in a state of the

United States and, for physicians, a current certification

by a recognized American medical specialty board in the

area or areas appropriate to the subject of the external

review; and

(4) have no history of disciplinary actions or

sanctions, including loss of staff privileges or

participation restrictions, that have been taken or are

pending by any hospital, governmental agency or unit, or

regulatory body that raise a substantial question as to the

clinical reviewer's physical, mental, or professional

competence or moral character.

(c) In addition to the requirements set forth in subsection

(a), an independent review organization may not own or control,

be a subsidiary of, or in any way be owned, or controlled by,

or exercise control with a health benefit plan, a national,

State, or local trade association of health benefit plans, or a

national, State, or local trade association of health care

providers.

(d) Conflicts of interest prohibited. In addition to the

requirements set forth in subsections (a), (b), and (c) of this

Section, to be approved pursuant to this Act to conduct an

external review of a specified case, neither the independent

review organization selected to conduct the external review nor

any clinical reviewer assigned by the independent organization

to conduct the external review may have a material

professional, familial or financial conflict of interest with

any of the following:

(1) the health carrier that is the subject of the

external review;

(2) the covered person whose treatment is the subject

of the external review or the covered person's authorized

representative;

(3) any officer, director or management employee of the

health carrier that is the subject of the external review;

(4) the health care provider, the health care

provider's medical group or independent practice

association recommending the health care service or

treatment that is the subject of the external review;

(5) the facility at which the recommended health care

service or treatment would be provided; or

(6) the developer or manufacturer of the principal

drug, device, procedure, or other therapy being

recommended for the covered person whose treatment is the

subject of the external review.

(e) An independent review organization that is accredited

by a nationally recognized private accrediting entity that has

independent review accreditation standards that the Director

has determined are equivalent to or exceed the minimum

qualifications of this Section shall be presumed to be in

compliance with this Section and shall be eligible for approval

under this Act.

(f) An independent review organization shall be unbiased.

An independent review organization shall establish and

maintain written procedures to ensure that it is unbiased in

addition to any other procedures required under this Section.

(g) Nothing in this Act precludes or shall be interpreted

to preclude a health carrier from contracting with approved

independent review organizations to conduct external reviews

assigned to it from such health carrier.

(Source: P.A. 96-857, eff. 7-1-10.)

(215 ILCS 180/65)

Sec. 65. External review reporting requirements.

(a) Each health carrier shall maintain written records in

the aggregate, by state, and for each type of health benefit

plan offered by the health carrier on all requests for external

review that the health carrier received notice from the

Director for each calendar year and submit a report to the

Director in the format specified by the Director by March 1 of

each year.

(a-5) An independent review organization assigned pursuant

to this Act to conduct an external review shall maintain

written records in the aggregate by state and by health carrier

on all requests for external review for which it conducted an

external review during a calendar year and submit a report in

the format specified by the Director by March 1 of each year.

(a-10) The report required by subsection (a-5) shall

include in the aggregate by state, and for each health carrier:

(1) the total number of requests for external review;

(2) the number of requests for external review resolved

and, of those resolved, the number resolved upholding the

adverse determination or final adverse determination and

the number resolved reversing the adverse determination or

final adverse determination;

(3) the average length of time for resolution;

(4) a summary of the types of coverages or cases for

which an external review was sought, as provided in the

format required by the Director;

(5) the number of external reviews that were terminated

as the result of a reconsideration by the health carrier of

its adverse determination or final adverse determination

after the receipt of additional information from the

covered person or the covered person's authorized

representative; and

(6) any other information the Director may request or

require.

(a-15) The independent review organization shall retain

the written records required pursuant to this Section for at

least 3 years.

(b) The report required under subsection (a) of this

Section shall include in the aggregate, by state, and by type

of health benefit plan:

(1) the total number of requests for external review;

(2) the total number of requests for expedited external

review;

(3) the total number of requests for external review

denied;

(4) the number of requests for external review

resolved, including:

(A) the number of requests for external review

resolved upholding the adverse determination or final

adverse determination;

(B) the number of requests for external review

resolved reversing the adverse determination or final

adverse determination;

(C) the number of requests for expedited external

review resolved upholding the adverse determination or

final adverse determination; and

(D) the number of requests for expedited external

review resolved reversing the adverse determination or

final adverse determination;

(5) the average length of time for resolution for an

external review;

(6) the average length of time for resolution for an

expedited external review;

(7) a summary of the types of coverages or cases for

which an external review was sought, as specified below:

(A) denial of care or treatment (dissatisfaction

regarding prospective non-authorization of a request

for care or treatment recommended by a provider

excluding diagnostic procedures and referral requests;

partial approvals and care terminations are also

considered to be denials);

(B) denial of diagnostic procedure

(dissatisfaction regarding prospective

non-authorization of a request for a diagnostic

procedure recommended by a provider; partial approvals

are also considered to be denials);

(C) denial of referral request (dissatisfaction

regarding non-authorization of a request for a

referral to another provider recommended by a PCP);

(D) claims and utilization review (dissatisfaction

regarding the concurrent or retrospective evaluation

of the coverage, medical necessity, efficiency or

appropriateness of health care services or treatment

plans; prospective "Denials of care or treatment",

"Denials of diagnostic procedures" and "Denials of

referral requests" should not be classified in this

category, but the appropriate one above);

(8) the number of external reviews that were terminated

as the result of a reconsideration by the health carrier of

its adverse determination or final adverse determination

after the receipt of additional information from the

covered person or the covered person's authorized

representative; and

(9) any other information the Director may request or

require.

(Source: P.A. 96-857, eff. 7-1-10.)

(215 ILCS 180/75)

Sec. 75. Disclosure requirements.

(a) Each health carrier shall include a description of the

external review procedures in, or attached to, the policy,

certificate, membership booklet, and outline of coverage or

other evidence of coverage it provides to covered persons.

(b) The description required under subsection (a) of this

Section shall include a statement that informs the covered

person of the right of the covered person to file a request for

an external review of an adverse determination or final adverse

determination with the Director health carrier. The statement

shall explain that external review is available when the

adverse determination or final adverse determination involves

an issue of medical necessity, appropriateness, health care

setting, level of care, or effectiveness. The statement shall

include the toll-free telephone number and address of the

Office of Consumer Health Insurance within the Department of

Insurance.

(Source: P.A. 96-857, eff. 7-1-10.)

(215 ILCS 180/80 new)

Sec. 80. Administration and enforcement.

(a) The Director of Insurance may adopt rules necessary to

implement the Department's responsibilities under this Act.

(b) The Director is authorized to make use of any of the

powers established under the Illinois Insurance Code to enforce

the laws of this State. This includes but is not limited to,

the Director's administrative authority to investigate, issue

subpoenas, conduct depositions and hearings, issue orders,

including, without limitation, orders pursuant to Article XII

1/2 and Section 401.1 of the Illinois Insurance Code, and

impose penalties.

Section 99. Effective date. This Act takes effect on July

1, 2011.