SB2787 EnrolledLRB099 16154 MLM 40480 b


  
1    AN ACT concerning regulation.
  
 
2    Be it enacted by the People of the State of Illinois,
 
3represented in the General Assembly:
  
 
 
4    Section 5. The Health Carrier External Review Act is 
5amended  by changing Section 65 as follows:
 
6    (215 ILCS 180/65)

7    Sec. 65. External review reporting requirements.  
8    (a) Each health carrier shall maintain written records in 
9the aggregate, by state, and for each type of health benefit 
10plan offered by the health carrier on all requests for external 
11review that the health carrier received notice from the 
12Director for each calendar year and submit a report to the 
13Director in the format specified by the Director by June 1 
14March 1 of each year.
15    (a-5) An independent review organization assigned pursuant 
16to this Act to conduct an external review shall maintain 
17written records in the aggregate by state and by health carrier 
18on all requests for external review for which it conducted an 
19external review during a calendar year and submit a report in 
20the format specified by the Director by March 1 of each year.
21    (a-10) The report required by subsection (a-5) shall 
22include in the aggregate by state, and for each health carrier:
23        (1) the total number of requests for external review;
 
 
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1        (2) the number of requests for external review resolved 
2    and, of those resolved, the number resolved upholding the 
3    adverse determination or final adverse determination and 
4    the number resolved reversing the adverse determination or 
5    final adverse determination;
6        (3) the average length of time for resolution;
7        (4) a summary of the types of coverages or cases for 
8    which an external review was sought, as provided in the 
9    format required by the Director;
10        (5) the number of external reviews that were terminated 
11    as the result of a reconsideration by the health carrier of 
12    its adverse determination or final adverse determination 
13    after the receipt of additional information from the 
14    covered person or the covered person's authorized 
15    representative; and
16        (6) any other information the Director may request or 
17    require.
18    (a-15) The independent review organization shall retain 
19the written records required pursuant to this Section for at 
20least 3 years. 
21    (b) The report required under subsection (a) of this 
22Section shall include in the aggregate, by state, and by type 
23of health benefit plan:

24        (1) the total number of requests for external review;
25        (2) the total number of requests for expedited external 
26    review;


 
 
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1        (3) the total number of requests for external review 
2    denied;
3        (4) the number of requests for external review 
4    resolved, including:
5            (A) the number of requests for external review 
6        resolved upholding the adverse determination or final 
7        adverse determination;
8            (B) the number of requests for external review 
9        resolved reversing the adverse determination or final 
10        adverse determination;
11            (C) the number of requests for expedited external 
12        review resolved upholding the adverse determination or 
13        final adverse determination; and
14            (D) the number of requests for expedited external 
15        review resolved reversing the adverse determination or 
16        final adverse determination;
17        (5) the average length of time for resolution for an 
18    external review;
19        (6) the average length of time for resolution for an 
20    expedited external review;
21        (7) a summary of the types of coverages or cases for 
22    which an external review was sought, as specified below:

23            (A) denial of care or treatment (dissatisfaction 
24        regarding prospective non-authorization of a request 
25        for care or treatment recommended by a provider 
26        excluding diagnostic procedures and referral requests;  
 
 
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1        partial approvals and care terminations are also 
2        considered to be denials);
3            (B) denial of diagnostic procedure 
4        (dissatisfaction regarding prospective 
5        non-authorization of a request for a diagnostic 
6        procedure recommended by a provider; partial approvals 
7        are also considered to be denials);
8            (C) denial of referral request (dissatisfaction 
9        regarding non-authorization of a request for a 
10        referral to another provider recommended by a PCP);
11            (D) claims and utilization review (dissatisfaction 
12        regarding the concurrent or retrospective evaluation 
13        of the coverage, medical necessity, efficiency or 
14        appropriateness of health care services or treatment 
15        plans; prospective "Denials of care or treatment", 
16        "Denials of diagnostic procedures" and "Denials of 
17        referral requests" should not be classified in this 
18        category, but the appropriate one above);

19        (8) the number of external reviews that were terminated 
20    as the result of a reconsideration by the health carrier of 
21    its adverse determination or final adverse determination 
22    after the receipt of additional information from the 
23    covered person or the covered person's authorized 
24    representative; and
25        (9) any other information the Director may request or 
26    require.


 
 
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1(Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.)
 
 
2    Section 99. Effective date. This Act takes effect January 
31, 2017.