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1 | | persons who are enrolled under Article V of the Illinois |
2 | | Public Aid Code or under the Children's Health Insurance |
3 | | Program Act, amended, delivered, issued, or renewed on or |
4 | | after the effective date of this Act, with the exception of |
5 | | employee or employer self-insured health benefit plans under |
6 | | the federal Employee Retirement Income Security Act of 1974, |
7 | | health care provided pursuant to the Workers' Compensation Act |
8 | | or the Workers' Occupational Diseases Act, and State employee |
9 | | health plans. This Act does not diminish a health care plan's |
10 | | duties and responsibilities under other federal or State law |
11 | | or rules promulgated thereunder.
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12 | | Section 15. Definitions. As used in this Act:
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13 | | "Adverse determination" has the meaning given to that term |
14 | | in Section 10 of the Health Carrier External Review Act.
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15 | | "Appeal" means a formal request, either orally or in |
16 | | writing, to reconsider an adverse determination.
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17 | | "Approval" means a determination by a utilization review |
18 | | organization that a health care service has been reviewed and, |
19 | | based on the information provided, satisfies the utilization |
20 | | review organization's requirements for medical necessity and |
21 | | appropriateness.
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22 | | "Clinical review criteria" has the meaning given to that |
23 | | term in Section 10 of the Health Carrier External Review Act.
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24 | | "Department" means the Department of Insurance.
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25 | | "Emergency medical condition" has the meaning given to |
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1 | | that term in Section 10 of the Managed Care Reform and Patient |
2 | | Rights Act.
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3 | | "Emergency services" has the meaning given to that term in |
4 | | federal health insurance reform requirements for the group and |
5 | | individual health insurance markets, 45 CFR 147.138.
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6 | | "Enrollee" has the meaning given to that term in Section |
7 | | 10 of the Managed Care Reform and Patient Rights Act.
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8 | | "Health care professional" has the meaning given to that |
9 | | term in Section 10 of the Managed Care Reform and Patient |
10 | | Rights Act.
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11 | | "Health care provider" has the meaning given to that term |
12 | | in Section 10 of the Managed Care Reform and Patient Rights |
13 | | Act.
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14 | | "Health care service" means any services or level of |
15 | | services included in the furnishing to an individual of |
16 | | medical care or the hospitalization incident to the furnishing |
17 | | of such care, as well as the furnishing to any person of any |
18 | | other services for the purpose of preventing, alleviating, |
19 | | curing, or healing human illness or injury, including |
20 | | behavioral health, mental health, home health, and |
21 | | pharmaceutical services and products.
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22 | | "Health insurance issuer" has the meaning given to that |
23 | | term in Section 5 of the Illinois Health Insurance Portability |
24 | | and Accountability Act.
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25 | | "Medically necessary" means a health care professional |
26 | | exercising prudent clinical judgment would provide care to a |
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1 | | patient for the purpose of preventing, diagnosing, or treating |
2 | | an illness, injury, disease, or its symptoms and that are: (i) |
3 | | in accordance with generally accepted standards of medical |
4 | | practice; (ii) clinically appropriate in terms of type, |
5 | | frequency, extent, site, and duration and are considered |
6 | | effective for the patient's illness, injury, or disease; and |
7 | | (iii) not primarily for the convenience of the patient, |
8 | | treating physician, other health care professional, caregiver, |
9 | | family member, or other interested party, but focused on what |
10 | | is best for the patient's health outcome.
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11 | | "Physician" means a person licensed under the Medical |
12 | | Practice Act of 1987 to practice medicine in all its branches.
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13 | | "Prior authorization" means the process by which |
14 | | utilization review organizations determine the medical |
15 | | necessity and medical appropriateness of otherwise covered |
16 | | health care services before the rendering of such health care |
17 | | services. "Prior authorization" includes any utilization |
18 | | review organization's requirement that an enrollee, health |
19 | | care professional, or health care provider notify the |
20 | | utilization review organization before, at the time of, or |
21 | | concurrent to providing a health care service.
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22 | | "Urgent health care service" means a health care service |
23 | | with respect to which the application of the time periods for |
24 | | making a non-expedited prior authorization that in the opinion |
25 | | of a health care professional with knowledge of the enrollee's |
26 | | medical condition:
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1 | | (1) could seriously jeopardize the life or health of |
2 | | the enrollee or the ability of the enrollee to regain |
3 | | maximum function; or
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4 | | (2) could subject the enrollee to severe pain that |
5 | | cannot be adequately managed without the care or treatment |
6 | | that is the subject of the utilization review.
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7 | | "Urgent health care service" does not include emergency |
8 | | services.
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9 | | "Utilization review organization" has the meaning given to |
10 | | that term in 50 Ill. Adm. Code 4520.30.
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11 | | Section 20. Disclosure and review of prior authorization |
12 | | requirements.
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13 | | (a) A health insurance issuer shall maintain a complete |
14 | | list of services for which prior authorization is required, |
15 | | including for all services where prior authorization is |
16 | | performed by an entity under contract with the health |
17 | | insurance issuer.
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18 | | (b) A health insurance issuer shall make any current prior |
19 | | authorization requirements and restrictions, including the |
20 | | written clinical review criteria, readily accessible and |
21 | | conspicuously posted on its website to enrollees, health care |
22 | | professionals, and health care providers. Content published by |
23 | | a third party and licensed for use by a health insurance issuer |
24 | | or its contracted utilization review organization may be made |
25 | | available through the health insurance issuer's or its |
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1 | | contracted utilization review organization's secure, |
2 | | password-protected website so long as the access requirements |
3 | | of the website do not unreasonably restrict access. |
4 | | Requirements shall be described in detail, written in easily |
5 | | understandable language, and readily available to the health |
6 | | care professional and health care provider at the point of |
7 | | care. The website shall indicate for each service subject to |
8 | | prior authorization:
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9 | | (1) when prior authorization became required for |
10 | | policies issued or delivered in Illinois, including the |
11 | | effective date or dates and the termination date or dates, |
12 | | if applicable, in Illinois;
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13 | | (2) the date the Illinois-specific requirement was |
14 | | listed on the health insurance issuer's or its contracted |
15 | | utilization review organization's website; and
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16 | | (3) where applicable, the date that prior |
17 | | authorization was removed for Illinois.
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18 | | (c) The clinical review criteria must:
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19 | | (1) be based on nationally recognized, generally |
20 | | accepted standards except where State law provides its own |
21 | | standard;
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22 | | (2) be developed in accordance with the current |
23 | | standards of a national medical accreditation entity;
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24 | | (3) ensure quality of care and access to needed health |
25 | | care services;
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26 | | (4) be evidence-based;
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1 | | (5) be sufficiently flexible to allow deviations from |
2 | | norms when justified on a case-by-case basis;
and |
3 | | (6) be evaluated and updated, if necessary, at least |
4 | | annually. |
5 | | (d) A health insurance issuer shall not deny a claim for |
6 | | failure to obtain prior authorization if the prior |
7 | | authorization requirement was not in effect on the date of |
8 | | service on the claim.
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9 | | (e) Neither a health insurance issuer nor a contracted |
10 | | utilization review organization shall deny prior authorization |
11 | | of a health care service solely based on the grounds that:
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12 | | (1) no independently developed, evidence-based |
13 | | standards can be derived from reliable scientific evidence |
14 | | or documents published by professional societies;
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15 | | (2) evidence-based standards conflict;
or |
16 | | (3) evidence-based standards from expert consensus |
17 | | panels do not exist.
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18 | | (f) A health insurance issuer or its contracted |
19 | | utilization review organization shall not deem as incidental |
20 | | or deny supplies or health care services that are routinely |
21 | | used as part of a health care service when:
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22 | | (1) an associated health care service has received |
23 | | prior authorization; or
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24 | | (2) prior authorization for the health care service is |
25 | | not required.
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26 | | (g) If a health insurance issuer intends either to |
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1 | | implement a new prior authorization requirement or restriction |
2 | | or amend an existing requirement or restriction, the health |
3 | | insurance issuer shall provide enrollees, contracted health |
4 | | care professionals, and contracted health care providers of |
5 | | enrollees written notice of the new or amended requirement or |
6 | | amendment no less than 60 days before the requirement or |
7 | | restriction is implemented. The written notice may be provided |
8 | | in an electronic format, including email or facsimile, if the |
9 | | enrollee, health care professional, or health care provider |
10 | | has agreed in advance to receive notices electronically. The |
11 | | health insurance issuer shall ensure that the new or amended |
12 | | requirement is not implemented unless the health insurance |
13 | | issuer's or its contracted utilization review organization's |
14 | | website has been updated to reflect the new or amended |
15 | | requirement or restriction.
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16 | | (h) Entities utilizing prior authorization shall make |
17 | | statistics available regarding prior authorization approvals |
18 | | and denials on their website in a readily accessible format. |
19 | | The categories must be updated quarterly and include all of |
20 | | the following information:
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21 | | (1) a list of all health care services, including |
22 | | medications, that are subject to prior authorization;
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23 | | (2) the total number of prior authorization requests |
24 | | received;
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25 | | (3) the number of prior authorization requests denied |
26 | | during the previous plan year by the health insurance |
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1 | | issuer or its contracted utilization review organization |
2 | | with respect to each service described in paragraph (1) |
3 | | and the top 5 reasons for denial;
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4 | | (4) the number of requests described in paragraph (3) |
5 | | that were appealed, the number of the appealed requests |
6 | | that upheld the adverse determination, and the number of |
7 | | appealed requests that reversed the adverse determination;
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8 | | (5) the average time between submission and response;
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9 | | and |
10 | | (6) any other information as the Director determines |
11 | | appropriate.
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12 | | Section 25. Health insurance issuer's and its contracted |
13 | | utilization review organization's obligations with respect to |
14 | | prior authorizations in nonurgent circumstances. If a health |
15 | | insurance issuer requires prior authorization of a health care |
16 | | service, the health insurance issuer or its contracted |
17 | | utilization review organization must make an approval or |
18 | | adverse determination and notify the enrollee, the enrollee's |
19 | | health care professional, and the enrollee's health care |
20 | | provider of the approval or adverse determination as required |
21 | | by applicable law, but no later than 72 hours after obtaining |
22 | | all necessary information to make the approval or adverse |
23 | | determination. As used in this Section, "necessary |
24 | | information" includes the results of any face-to-face clinical |
25 | | evaluation or second opinion that may be required.
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1 | | Section 30. Health insurance issuer's and its contracted |
2 | | utilization review organization's obligations with respect to |
3 | | prior authorizations concerning urgent health care services.
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4 | | (a) A health insurance issuer or its contracted |
5 | | utilization review organization must render an approval or |
6 | | adverse determination concerning urgent care services and any |
7 | | services for any current or prospective resident of a skilled |
8 | | nursing facility and notify the enrollee, the enrollee's |
9 | | health care professional, and the enrollee's health care |
10 | | provider of that approval or adverse determination not later |
11 | | than 24 hours after receiving all information needed to |
12 | | complete the review of the requested health care services.
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13 | | (b) To facilitate the rendering of a prior authorization |
14 | | determination in conformance with this Section, a health |
15 | | insurance issuer or its contracted utilization review |
16 | | organization must establish and provide access to a hotline |
17 | | that is staffed 24 hours per day, 7 days per week by |
18 | | appropriately trained and licensed clinical personnel who have |
19 | | access to physicians for consultation, designated by the plan |
20 | | to make such determinations for prior authorization concerning |
21 | | urgent care services.
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22 | | Section 35. Health insurance issuer's and its contracted |
23 | | utilization review organization's obligations with respect to |
24 | | prior authorization concerning emergency health care services.
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1 | | (a) A health insurance issuer shall cover emergency health |
2 | | care services necessary to screen and stabilize an enrollee. |
3 | | If a health care professional or health care provider |
4 | | certifies in writing to a health insurance issuer within 72 |
5 | | hours after an enrollee's admission that the enrollee's |
6 | | condition required emergency health care services, that |
7 | | certification shall create a presumption that the emergency |
8 | | health care services were medically necessary and such |
9 | | presumption may be rebutted only if the health insurance |
10 | | issuer or its contracted utilization review organization can |
11 | | establish, with clear and convincing evidence, that the |
12 | | emergency health care services were not medically necessary.
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13 | | (b) If an enrollee receives an emergency health care |
14 | | service that requires immediate post-evaluation or |
15 | | post-stabilization services, a health insurance issuer or its |
16 | | contracted utilization review organization shall make a prior |
17 | | authorization determination within 60 minutes after receiving |
18 | | a request; if the prior authorization determination is not |
19 | | made within 60 minutes, the services shall be deemed approved.
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20 | | Section 40. Personnel qualified to make adverse |
21 | | determinations of a prior authorization request. A health |
22 | | insurance issuer or its contracted utilization review |
23 | | organization must ensure that all adverse determinations are |
24 | | made by a physician when the request is by a physician or a |
25 | | representative of a physician. The physician must:
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1 | | (1) possess a current and valid nonrestricted license |
2 | | to practice medicine in all its branches in any United |
3 | | States jurisdiction;
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4 | | (2) practice in the same or similar specialty as the |
5 | | physician who typically manages the medical condition or |
6 | | disease or provides the health care service involved in |
7 | | the request; and
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8 | | (3) have experience treating patients with the medical |
9 | | condition or disease for which the health care service is |
10 | | being requested.
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11 | | Notwithstanding the foregoing, a licensed health care |
12 | | professional who satisfies the requirements of this Section |
13 | | may make an adverse determination of a prior authorization |
14 | | request submitted by a health care professional licensed in |
15 | | the same profession.
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16 | | Section 45. Consultation before issuing an adverse |
17 | | determination of a prior authorization. If a health insurance |
18 | | issuer or its contracted utilization review organization is |
19 | | questioning the medical necessity of a health care service, |
20 | | the health insurance issuer or its contracted utilization |
21 | | review organization must notify the enrollee's health care |
22 | | professional and health care provider that medical necessity |
23 | | is being questioned. Before issuing an adverse determination, |
24 | | the enrollee's health care professional and health care |
25 | | provider must have the opportunity to discuss the medical |
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1 | | necessity of the health care service on the telephone or by |
2 | | other agreeable method with the health care professional who |
3 | | will be responsible for issuing the prior authorization |
4 | | determination of the health care service under review.
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5 | | Section 50. Requirements applicable to the physician who |
6 | | can review consultations and appeals. A health insurance |
7 | | issuer or its contracted utilization review organization must |
8 | | ensure that all appeals are reviewed by a physician. The |
9 | | physician must:
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10 | | (1) possess a current and valid nonrestricted license |
11 | | to practice medicine in any United States jurisdiction;
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12 | | (2) be currently in active practice in the same or |
13 | | similar specialty as a physician who typically manages the |
14 | | medical condition or disease;
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15 | | (3) be knowledgeable of, and have experience |
16 | | providing, the health care services under appeal;
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17 | | (4) not have been directly involved in making the |
18 | | adverse determination; and
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19 | | (5) consider all known clinical aspects of the health |
20 | | care service under review, including, but not limited to, |
21 | | a review of all pertinent medical records provided to the |
22 | | health insurance issuer or its contracted utilization |
23 | | review organization by the enrollee's health care |
24 | | professional or health care provider and any medical |
25 | | literature provided to the health insurance issuer or its |
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1 | | contracted utilization review organization by the health |
2 | | care professional or health care provider.
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3 | | Section 55. Review of prior authorization requirements. A |
4 | | health insurance issuer shall periodically review its prior |
5 | | authorization requirements and consider removal of prior |
6 | | authorization requirements:
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7 | | (1) where a medication or procedure prescribed is |
8 | | customary and properly indicated or is a treatment for the |
9 | | clinical indication as supported by peer-reviewed medical |
10 | | publications;
or |
11 | | (2) for patients currently managed with an established |
12 | | treatment regimen.
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13 | | Section 60. Denial.
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14 | | (a) The health insurance issuer or its contracted |
15 | | utilization review organization may not revoke, limit, |
16 | | condition, or restrict a previously issued prior authorization |
17 | | approval.
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18 | | (b) Notwithstanding any other provision of law, if a claim |
19 | | is properly coded and submitted timely to a health insurance |
20 | | issuer, the health insurance issuer shall make payment on |
21 | | claims for health care services for which prior authorization |
22 | | was required and approval received before the rendering of |
23 | | health care services, unless one of the following occurs:
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24 | | (1) it is timely determined that the enrollee's health |
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1 | | care professional or health care provider knowingly |
2 | | provided health care services that required prior |
3 | | authorization from the health insurance issuer or its |
4 | | contracted utilization review organization without first |
5 | | obtaining prior authorization for those health care |
6 | | services;
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7 | | (2) it is timely determined that the health care |
8 | | services claimed were not performed;
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9 | | (3) it is timely determined that the health care |
10 | | services rendered were contrary to the instructions of the |
11 | | health insurance issuer or its contracted utilization |
12 | | review organization or delegated physician reviewer if |
13 | | contact was made between those parties before the service |
14 | | being rendered;
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15 | | (4) it is timely determined that the enrollee |
16 | | receiving such health care services was not an enrollee of |
17 | | the health care plan; or
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18 | | (5) the approval was based upon a material |
19 | | misrepresentation by the enrollee or health care provider; |
20 | | as used in this paragraph (5), "material" means a fact or |
21 | | situation that is not merely technical in nature and |
22 | | results or could result in a substantial change in the |
23 | | situation.
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24 | | Section 65. Length of prior authorization approval. A |
25 | | prior authorization approval shall be valid for the lesser of |
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1 | | 12 months after the date the health care professional or |
2 | | health care provider receives the prior authorization approval |
3 | | or the length of treatment as determined by the patient's |
4 | | health care professional, and the approval period shall be |
5 | | effective regardless of any changes, including any changes in |
6 | | dosage for a prescription drug prescribed by the health care |
7 | | professional. This Section shall not apply to the prescription |
8 | | of benzodiazepines or Schedule II narcotic drugs, such as |
9 | | opioids. Except to the extent required by medical exceptions |
10 | | processes for prescription drugs, nothing in this Section |
11 | | shall require a policy to cover any care, treatment, or |
12 | | services for any health condition that the terms of coverage |
13 | | otherwise completely exclude from the policy's covered |
14 | | benefits without regard for whether the care, treatment, or |
15 | | services are medically necessary.
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16 | | Section 70. Length of prior authorization approval for |
17 | | treatment for chronic or long-term conditions. If a health |
18 | | insurance issuer requires a prior authorization for a |
19 | | recurring health care service or maintenance medication for |
20 | | the treatment of a chronic or long-term condition, the |
21 | | approval shall remain valid for the lesser of 12 months from |
22 | | the date the health care professional or health care provider |
23 | | receives the prior authorization approval or the length of the |
24 | | treatment as determined by the patient's health care |
25 | | professional. Except to the extent required by medical |
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1 | | exceptions processes for prescription drugs, nothing in this |
2 | | Section shall require a policy to cover any care, treatment, |
3 | | or services for any health condition that the terms of |
4 | | coverage otherwise completely exclude from the policy's |
5 | | covered benefits without regard for whether the care, |
6 | | treatment, or services are medically necessary.
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7 | | Section 75. Continuity of care for enrollees.
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8 | | (a) On receipt of information documenting a prior |
9 | | authorization approval from the enrollee or from the |
10 | | enrollee's health care professional or health care provider, a |
11 | | health insurance issuer shall honor a prior authorization |
12 | | granted to an enrollee from a previous health insurance issuer |
13 | | or its contracted utilization review organization for at least |
14 | | the initial 90 days of an enrollee's coverage under a new |
15 | | health plan.
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16 | | (b) During the time period described in subsection (a), a |
17 | | health insurance issuer or its contracted utilization review |
18 | | organization may perform its own review to grant a prior |
19 | | authorization approval subject to the terms of the member's |
20 | | coverage agreement.
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21 | | (c) If there is a change in coverage of or approval |
22 | | criteria for a previously authorized health care service, the |
23 | | change in coverage or approval criteria does not affect an |
24 | | enrollee who received prior authorization approval before the |
25 | | effective date of the change for the remainder of the |
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1 | | enrollee's plan year.
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2 | | (d) Except to the extent required by medical exceptions |
3 | | processes for prescription drugs, nothing in this Section |
4 | | shall require a policy to cover any care, treatment, or |
5 | | services for any health condition that the terms of coverage |
6 | | otherwise completely exclude from the policy's covered |
7 | | benefits without regard for whether the care, treatment, or |
8 | | services are medically necessary.
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9 | | Section 80. Health care services deemed authorized if a |
10 | | health insurance issuer or its contracted utilization review |
11 | | organization fails to comply with the requirements of this |
12 | | Act. A failure by a health insurance issuer or its contracted |
13 | | utilization review organization to comply with the deadlines |
14 | | and other requirements specified in this Act shall result in |
15 | | any health care services subject to review to be automatically |
16 | | deemed authorized by the health insurance issuer or its |
17 | | contracted utilization review organization.
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18 | | Section 85. Severability. If any provision of this Act or |
19 | | its application to any person or circumstance is held invalid, |
20 | | the invalidity does not affect other provisions or |
21 | | applications of this Act that can be given effect without the |
22 | | invalid provision or application, and to this end the |
23 | | provisions of this Act are declared to be severable.
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1 | | Section 90. Administration and enforcement.
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2 | | (a) The Department shall enforce the provisions of this |
3 | | Act pursuant to the enforcement powers granted to it by law. To |
4 | | enforce the provisions of this Act, the Director is hereby |
5 | | granted specific authority to issue a cease and desist order |
6 | | or require a utilization review organization or health |
7 | | insurance issuer to submit a plan of correction for violations |
8 | | of this Act, or both, in accordance with the requirements and |
9 | | authority set forth in Section 85 of the Managed Care Reform |
10 | | and Patient Rights Act. Subject to the provisions of the |
11 | | Illinois Administrative Procedure Act, the Director may, |
12 | | pursuant to Section 403A of the Illinois Insurance Code, |
13 | | impose upon a utilization review organization or health |
14 | | insurance issuer an administrative fine not to exceed $250,000 |
15 | | for failure to submit a requested plan of correction, failure |
16 | | to comply with its plan of correction, or repeated violations |
17 | | of this Act.
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18 | | (b) Any person who believes that his or her utilization |
19 | | review organization or health insurance issuer is in violation |
20 | | of the provisions of this Act may file a complaint with the |
21 | | Department. The Department shall review all complaints |
22 | | received and investigate all complaints that it deems to state |
23 | | a potential violation. The Department shall fairly, |
24 | | efficiently, and timely review and investigate complaints. |
25 | | Utilization review organizations found to be in violation of |
26 | | this Act shall be penalized in accordance with this Section.
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1 | | (c) The Department of Healthcare and Family Services shall |
2 | | enforce the provisions of this Act as it applies to persons |
3 | | enrolled under Article V of the Illinois Public Aid Code or |
4 | | under the Children's Health Insurance Program Act.
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5 | | Section 900. The Illinois Insurance Code is amended by |
6 | | changing Section 370g as follows:
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7 | | (215 ILCS 5/370g) (from Ch. 73, par. 982g)
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8 | | Sec. 370g. Definitions. As used in this Article, the |
9 | | following definitions
apply:
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10 | | (a) "Health care services" means health care services or |
11 | | products
rendered or sold by a provider within the scope of the |
12 | | provider's license
or legal authorization. The term includes, |
13 | | but is not limited to, hospital,
medical, surgical, dental, |
14 | | vision and pharmaceutical services or products.
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15 | | (b) "Insurer" means an insurance company or a health |
16 | | service corporation
authorized in this State to issue policies |
17 | | or subscriber contracts which
reimburse for expenses of health |
18 | | care services.
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19 | | (c) "Insured" means an individual entitled to |
20 | | reimbursement for expenses
of health care services under a |
21 | | policy or subscriber contract issued or
administered by an |
22 | | insurer.
|
23 | | (d) "Provider" means an individual or entity duly licensed |
24 | | or legally
authorized to provide health care services.
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1 | | (e) "Noninstitutional provider" means any person licensed |
2 | | under the Medical
Practice Act of 1987, as now or hereafter |
3 | | amended.
|
4 | | (f) "Beneficiary" means an individual entitled to |
5 | | reimbursement for
expenses of or the discount of provider fees |
6 | | for health care services under
a program where the beneficiary |
7 | | has an incentive to utilize the services of a
provider which |
8 | | has entered into an agreement or arrangement with an
|
9 | | administrator.
|
10 | | (g) "Administrator" means any person, partnership or |
11 | | corporation, other
than an insurer or health maintenance |
12 | | organization holding a certificate of
authority under the |
13 | | "Health Maintenance Organization Act", as now or hereafter
|
14 | | amended, that arranges, contracts with, or administers |
15 | | contracts with a
provider whereby beneficiaries are provided |
16 | | an incentive to use the services of
such provider.
|
17 | | (h) "Emergency medical condition" has the meaning given to |
18 | | that term in Section 10 of the Managed Care Reform and Patient |
19 | | Rights Act. means a medical condition manifesting
itself
by
|
20 | | acute symptoms of sufficient severity (including severe
pain) |
21 | | such that a prudent
layperson, who possesses an average |
22 | | knowledge of health and medicine, could
reasonably expect the |
23 | | absence of immediate medical attention to result in:
|
24 | | (1) placing the health of the individual (or, with |
25 | | respect to a pregnant
woman, the
health of the woman or her |
26 | | unborn child) in serious jeopardy;
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| | HB0711 Engrossed | - 22 - | LRB102 10190 BMS 20259 b |
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1 | | (2) serious
impairment to bodily functions; or
|
2 | | (3) serious dysfunction of any bodily organ
or part.
|
3 | | (Source: P.A. 91-617, eff. 1-1-00.)
|
4 | | Section 905. The Managed Care Reform and Patient Rights |
5 | | Act is amended by changing Sections 10 and 65 as follows:
|
6 | | (215 ILCS 134/10)
|
7 | | Sec. 10. Definitions.
|
8 | | "Adverse determination" means a determination by a health |
9 | | care plan under
Section 45 or by a utilization review program |
10 | | under Section
85 that
a health care service is not medically |
11 | | necessary.
|
12 | | "Clinical peer" means a health care professional who is in |
13 | | the same
profession and the same or similar specialty as the |
14 | | health care provider who
typically manages the medical |
15 | | condition, procedures, or treatment under
review.
|
16 | | "Department" means the Department of Insurance.
|
17 | | "Emergency medical condition" means a medical condition |
18 | | manifesting itself by
acute symptoms of sufficient severity, |
19 | | regardless of the final diagnosis given, such that a prudent
|
20 | | layperson, who possesses an average knowledge of health and |
21 | | medicine, could
reasonably expect the absence of immediate |
22 | | medical attention to result in:
|
23 | | (1) placing the health of the individual (or, with |
24 | | respect to a pregnant
woman, the
health of the woman or her |
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1 | | unborn child) in serious jeopardy;
|
2 | | (2) serious
impairment to bodily functions;
|
3 | | (3) serious dysfunction of any bodily organ
or part;
|
4 | | (4) inadequately controlled pain; or |
5 | | (5) with respect to a pregnant woman who is having |
6 | | contractions: |
7 | | (A) inadequate time to complete a safe transfer to |
8 | | another hospital before delivery; or |
9 | | (B) a transfer to another hospital may pose a |
10 | | threat to the health or safety of the woman or unborn |
11 | | child. |
12 | | "Emergency medical screening examination" means a medical |
13 | | screening
examination and
evaluation by a physician licensed |
14 | | to practice medicine in all its branches, or
to the extent |
15 | | permitted
by applicable laws, by other appropriately licensed |
16 | | personnel under the
supervision of or in
collaboration with a |
17 | | physician licensed to practice medicine in all its
branches to |
18 | | determine whether
the need for emergency services exists.
|
19 | | "Emergency services" means, with respect to an enrollee of |
20 | | a health care
plan,
transportation services, including but not |
21 | | limited to ambulance services, and
covered inpatient and |
22 | | outpatient hospital services
furnished by a provider
qualified |
23 | | to furnish those services that are needed to evaluate or |
24 | | stabilize an
emergency medical condition. "Emergency services" |
25 | | does not
refer to post-stabilization medical services.
|
26 | | "Enrollee" means any person and his or her dependents |
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1 | | enrolled in or covered
by a health care plan.
|
2 | | "Health care plan" means a plan, including, but not |
3 | | limited to, a health maintenance organization, a managed care |
4 | | community network as defined in the Illinois Public Aid Code, |
5 | | or an accountable care entity as defined in the Illinois |
6 | | Public Aid Code that receives capitated payments to cover |
7 | | medical services from the Department of Healthcare and Family |
8 | | Services, that establishes, operates, or maintains a
network |
9 | | of health care providers that has entered into an agreement |
10 | | with the
plan to provide health care services to enrollees to |
11 | | whom the plan has the
ultimate obligation to arrange for the |
12 | | provision of or payment for services
through organizational |
13 | | arrangements for ongoing quality assurance,
utilization review |
14 | | programs, or dispute resolution.
Nothing in this definition |
15 | | shall be construed to mean that an independent
practice |
16 | | association or a physician hospital organization that |
17 | | subcontracts
with
a health care plan is, for purposes of that |
18 | | subcontract, a health care plan.
|
19 | | For purposes of this definition, "health care plan" shall |
20 | | not include the
following:
|
21 | | (1) indemnity health insurance policies including |
22 | | those using a contracted
provider network;
|
23 | | (2) health care plans that offer only dental or only |
24 | | vision coverage;
|
25 | | (3) preferred provider administrators, as defined in |
26 | | Section 370g(g) of
the
Illinois Insurance Code;
|
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1 | | (4) employee or employer self-insured health benefit |
2 | | plans under the
federal Employee Retirement Income |
3 | | Security Act of 1974;
|
4 | | (5) health care provided pursuant to the Workers' |
5 | | Compensation Act or the
Workers' Occupational Diseases |
6 | | Act; and
|
7 | | (6) not-for-profit voluntary health services plans |
8 | | with health maintenance
organization
authority in |
9 | | existence as of January 1, 1999 that are affiliated with a |
10 | | union
and that
only extend coverage to union members and |
11 | | their dependents.
|
12 | | "Health care professional" means a physician, a registered |
13 | | professional
nurse,
or other individual appropriately licensed |
14 | | or registered
to provide health care services.
|
15 | | "Health care provider" means any physician, hospital |
16 | | facility, facility licensed under the Nursing Home Care Act, |
17 | | long-term care facility as defined in Section 1-113 of the |
18 | | Nursing Home Care Act, or other
person that is licensed or |
19 | | otherwise authorized to deliver health care
services. Nothing |
20 | | in this
Act shall be construed to define Independent Practice |
21 | | Associations or
Physician-Hospital Organizations as health |
22 | | care providers.
|
23 | | "Health care services" means any services included in the |
24 | | furnishing to any
individual of medical care, or the
|
25 | | hospitalization incident to the furnishing of such care, as |
26 | | well as the
furnishing to any person of
any and all other |
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1 | | services for the purpose of preventing,
alleviating, curing, |
2 | | or healing human illness or injury including behavioral |
3 | | health, mental health, home health ,
and pharmaceutical |
4 | | services and products.
|
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 | | "Stabilization" means, with respect to an emergency |
20 | | medical condition, to
provide such medical treatment of the |
21 | | condition as may be necessary to assure,
within reasonable |
22 | | medical probability, that no material deterioration
of the |
23 | | condition is likely to result.
|
24 | | "Utilization review" means the evaluation of the medical |
25 | | necessity,
appropriateness, and efficiency of the use of |
26 | | health care services, procedures,
and facilities.
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1 | | "Utilization review program" means a program established |
2 | | by a person to
perform utilization review.
|
3 | | (Source: P.A. 101-452, eff. 1-1-20 .)
|
4 | | (215 ILCS 134/65)
|
5 | | Sec. 65. Emergency services prior to stabilization.
|
6 | | (a) A health care plan
that provides or that is required by |
7 | | law to provide coverage for emergency
services shall provide |
8 | | coverage such that payment under this coverage is not
|
9 | | dependent upon whether the services are performed by a plan or |
10 | | non-plan health
care provider and without regard to prior |
11 | | authorization. This coverage shall be
at the same benefit |
12 | | level as if the services or treatment had been rendered by
the |
13 | | health care plan physician licensed to practice medicine in |
14 | | all
its branches or health care provider.
|
15 | | (b) Prior authorization or approval by the plan shall not |
16 | | be required for
emergency services.
|
17 | | (c) Coverage and payment shall only be retrospectively |
18 | | denied under the
following circumstances:
|
19 | | (1) upon reasonable determination that the emergency |
20 | | services claimed were
never performed;
|
21 | | (2) upon timely determination that the emergency |
22 | | evaluation and treatment
were
rendered to an enrollee who |
23 | | sought emergency services and whose circumstance
did not |
24 | | meet the definition of emergency medical condition;
|
25 | | (3) upon determination that the patient receiving such |
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1 | | services was not an
enrollee of the health care plan; or
|
2 | | (4) upon material misrepresentation by the enrollee or |
3 | | health care
provider; "material" means a fact or situation |
4 | | that is not merely technical in
nature and results or |
5 | | could result in a substantial change in the situation.
|
6 | | (d) When an enrollee presents to a hospital seeking |
7 | | emergency services,
the determination as to whether the need |
8 | | for those
services exists shall be made for purposes of |
9 | | treatment by a
physician licensed to practice medicine in all |
10 | | its branches or, to the extent
permitted by applicable law, by |
11 | | other appropriately licensed
personnel under the supervision |
12 | | of
or in collaboration with a physician licensed to practice |
13 | | medicine in all its
branches.
The physician or other
|
14 | | appropriate personnel shall indicate in the patient's chart |
15 | | the results of the
emergency medical screening examination.
|
16 | | (e) The appropriate use of the 911 emergency telephone |
17 | | system or its local
equivalent shall not be discouraged or |
18 | | penalized by the health care plan when
an emergency medical |
19 | | condition exists.
This provision shall not imply that the use |
20 | | of 911 or its local equivalent is a
factor in determining the |
21 | | existence of an emergency medical condition.
|
22 | | (f) The medical director's or his or her designee's
|
23 | | determination of whether the enrollee meets the standard of an |
24 | | emergency
medical condition shall be based solely upon the |
25 | | presenting symptoms documented
in the medical record at the |
26 | | time care was
sought.
Only a clinical peer may make an adverse |
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1 | | determination.
|
2 | | (g) Nothing in this Section shall prohibit the imposition |
3 | | of deductibles,
copayments, and co-insurance.
Nothing in this |
4 | | Section alters the prohibition on billing enrollees contained
|
5 | | in the Health Maintenance Organization Act.
|
6 | | (h) This Section shall apply to the types of companies |
7 | | subject to Section 155.36 of the Illinois Insurance Code. |
8 | | (Source: P.A. 91-617, eff. 1-1-00.)
|
9 | | Section 910. The Illinois Public Aid Code is amended by |
10 | | adding Section 5-5.12d as follows:
|
11 | | (305 ILCS 5/5-5.12d new) |
12 | | Sec. 5-5.12d. Managed care organization prior |
13 | | authorization of health care services. |
14 | | (a) As used in this Section, "health care service" has the |
15 | | meaning given to that term in the Prior Authorization Reform |
16 | | Act. |
17 | | (b) Notwithstanding any other provision of law to the |
18 | | contrary, all managed care organizations shall comply with the |
19 | | requirements of the Prior Authorization Reform Act.
|
20 | | Section 999. Effective date. This Act takes effect January |
21 | | 1, 2022.
|