Sen. Jacqueline Y. Collins

Filed: 3/25/2009

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 1506

2     AMENDMENT NO. ______. Amend Senate Bill 1506, AS AMENDED,
3 by replacing everything after the enacting clause with the
4 following:
 
5     "Section 1. Short title. This Act may be cited as the
6 Health Carrier External Review Act.
 
7     Section 5. Purpose and intent. The purpose of this Act is
8 to provide uniform standards for the establishment and
9 maintenance of external review procedures to assure that
10 covered persons have the opportunity for an independent review
11 of an adverse determination or final adverse determination, as
12 defined in this Act.
 
13     Section 10. Definitions. For the purposes of this Act:
14     "Adverse determination" means a determination by a health
15 carrier or its designee utilization review organization that an

 

 

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1 admission, availability of care, continued stay, or other
2 health care service that is a covered benefit has been reviewed
3 and, based upon the information provided, does not meet the
4 health carrier's requirements for medical necessity,
5 appropriateness, health care setting, level of care, or
6 effectiveness, and the requested service or payment for the
7 service is therefore denied, reduced, or terminated.
8     "Authorized representative" means:
9         (1) a person to whom a covered person has given express
10     written consent to represent the covered person in an
11     external review;
12         (2) a person authorized by law to provide substituted
13     consent for a covered person; or
14         (3) a family member of the covered person or the
15     covered person's health care provider only when the covered
16     person is unable to provide consent.
17     "Best evidence " means evidence based on:
18         (1) randomized clinical trials;
19         (2) if randomized clinical trials are not available,
20     then cohort studies or case-control studies;
21         (3) if items (1) and (2) are not available, then
22     case-series; or
23         (4) if items (1), (2), and (3) are not available, then
24     expert opinion.
25     "Case-series " means an evaluation of a series of patients
26 with a particular outcome, without the use of a control group.

 

 

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1     "Clinical review criteria" means the written screening
2 procedures, decision abstracts, clinical protocols, and
3 practice guidelines used by a health carrier to determine the
4 necessity and appropriateness of health care services.
5     "Cohort study" means a prospective evaluation of 2 groups
6 of patients with only one group of patients receiving specific
7 intervention.
8     "Covered benefits" or "benefits" means those health care
9 services to which a covered person is entitled under the terms
10 of a health benefit plan.
11     "Covered person" means a policyholder, subscriber,
12 enrollee, or other individual participating in a health benefit
13 plan.
14     "Director" means the Director of the Division of Insurance
15 within the Illinois Department of Financial and Professional
16 Regulation.
17     "Emergency medical condition" means the sudden onset of a
18 health condition or illness that requires immediate medical
19 attention, where failure to provide medical attention would
20 result in a serious impairment to bodily functions, serious
21 dysfunction of a bodily organ or part, or would place the
22 person's health in serious jeopardy.
23     "Emergency services" means health care items and services
24 furnished or required to evaluate and treat an emergency
25 medical condition.
26     "Evidence-based standard" means the conscientious,

 

 

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1 explicit, and judicious use of the current best evidence based
2 on an overall systematic review of the research in making
3 decisions about the care of individual patients.
4     "Expert opinion" means a belief or an interpretation by
5 specialists with experience in a specific area about the
6 scientific evidence pertaining to a particular service,
7 intervention, or therapy.
8     "Facility" means an institution providing health care
9 services or a health care setting.
10     "Final adverse determination" means an adverse
11 determination involving a covered benefit that has been upheld
12 by a health carrier, or its designee utilization review
13 organization, at the completion of the health carrier's
14 internal grievance process procedures as set forth by the
15 American Accreditation Health Care Commission.
16     "Health benefit plan" means a policy, contract,
17 certificate, plan, or agreement offered or issued by a health
18 carrier to provide, deliver, arrange for, pay for, or reimburse
19 any of the costs of health care services.
20     "Health care provider" or "provider" means a physician or
21 other health care practitioner licensed, accredited, or
22 certified to perform specified health care services consistent
23 with State law, responsible for recommending health care
24 services on behalf of a covered person.
25     "Health care services" means services for the diagnosis,
26 prevention, treatment, cure, or relief of a health condition,

 

 

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1 illness, injury, or disease.
2     "Health carrier" means an entity subject to the insurance
3 laws and regulations of this State, or subject to the
4 jurisdiction of the Director, that contracts or offers to
5 contract to provide, deliver, arrange for, pay for, or
6 reimburse any of the costs of health care services, including a
7 sickness and accident insurance company, a health maintenance
8 organization, a nonprofit hospital and health service
9 corporation, or any other entity providing a plan of health
10 insurance, health benefits, or health care services. "Health
11 carrier" also means Limited Health Service Organizations
12 (LHSO) and Voluntary Health Service Plans.
13     "Health carrier" does not include a managed care plan as
14 defined in the Managed Care Reform and Patient Rights Act.
15     "Health information" means information or data, whether
16 oral or recorded in any form or medium, and personal facts or
17 information about events or relationships that relate to:
18         (1) the past, present, or future physical, mental, or
19     behavioral health or condition of an individual or a member
20     of the individual's family;
21         (2) the provision of health care services to an
22     individual; or
23         (3) payment for the provision of health care services
24     to an individual.
25     "Independent review organization" means an entity that
26 conducts independent external reviews of adverse

 

 

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1 determinations and final adverse determinations.
2     "Medical or scientific evidence" means evidence found in
3 the following sources:
4         (1) peer-reviewed scientific studies published in or
5     accepted for publication by medical journals that meet
6     nationally recognized requirements for scientific
7     manuscripts and that submit most of their published
8     articles for review by experts who are not part of the
9     editorial staff;
10         (2) peer-reviewed medical literature, including
11     literature relating to therapies reviewed and approved by a
12     qualified institutional review board, biomedical
13     compendia, and other medical literature that meet the
14     criteria of the National Institutes of Health's Library of
15     Medicine for indexing in Index Medicus (Medline) and
16     Elsevier Science Ltd. for indexing in Excerpta Medicus
17     (EMBASE);
18         (3) medical journals recognized by the Secretary of
19     Health and Human Services under Section 1861(t)(2) of the
20     federal Social Security Act;
21         (4) the following standard reference compendia:
22             (a) The American Hospital Formulary Service-Drug
23         Information;
24             (b) Drug Facts and Comparisons;
25             (c) The American Dental Association Accepted
26         Dental Therapeutics; and

 

 

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1             (d) The United States Pharmacopoeia-Drug
2         Information;
3         (5) findings, studies, or research conducted by or
4     under the auspices of federal government agencies and
5     nationally recognized federal research institutes,
6     including:
7             (a) the federal Agency for Healthcare Research and
8         Quality;
9             (b) the National Institutes of Health;
10             (c) the National Cancer Institute;
11             (d) the National Academy of Sciences;
12             (e) the Centers for Medicare & Medicaid Services;
13             (f) the federal Food and Drug Administration; and
14             (g) any national board recognized by the National
15         Institutes of Health for the purpose of evaluating the
16         medical value of health care services; or
17         (6) any other medical or scientific evidence that is
18     comparable to the sources listed in items (1) through (5).
19     "Protected health information" means health information
20 (i) that identifies an individual who is the subject of the
21 information; or (ii) with respect to which there is a
22 reasonable basis to believe that the information could be used
23 to identify an individual.
24     "Retrospective review" means a review of medical necessity
25 conducted after services have been provided to a patient, but
26 does not include the review of a claim that is limited to an

 

 

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1 evaluation of reimbursement levels, veracity of documentation,
2 accuracy of coding, or adjudication for payment.
3     "Utilization review" has the meaning provided by the
4 American Accreditation Health Care Commission.
5     "Utilization review organization" means a utilization
6 review program as defined by the American Accreditation Health
7 Care Commission.
 
8     Section 15. Applicability and scope.
9     (a) Except as provided in subsection (b) of this Section,
10 this Act shall apply to all health carriers.
11     (b) The provisions of this Act shall not apply to a policy
12 or certificate that provides coverage only for a specified
13 disease, specified accident or accident-only coverage, credit,
14 dental, disability income, hospital indemnity, long-term care
15 insurance as defined by Article XIXA of the Illinois Insurance
16 Code, vision care, or any other limited supplemental benefit; a
17 Medicare supplement policy of insurance as defined by the
18 Director by regulation; coverage under a plan through Medicare,
19 Medicaid, or the federal employees health benefits program; any
20 coverage issued under Chapter 55 of Title 10, U.S. Code and any
21 coverage issued as supplement to that coverage; any coverage
22 issued as supplemental to liability insurance, workers'
23 compensation, or similar insurance; automobile medical-payment
24 insurance or any insurance under which benefits are payable
25 with or without regard to fault, whether written on a group

 

 

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1 blanket or individual basis; or any managed care plan as
2 defined in the Managed Care Reform and Patient Rights Act.
 
3     Section 20. Notice of right to external review.
4     (a) At the same time the health carrier sends written
5 notice of an adverse determination upon completion of the
6 health carrier's utilization review process as provided by the
7 American Accreditation Health Care Commission and a final
8 adverse determination, a health carrier shall notify a covered
9 person and a covered person's health care provider in writing
10 of the covered person's right to request an external review as
11 provided by this Act.
12         (1) The written notice required shall include the
13     following, or substantially equivalent, language: "We have
14     denied your request for the provision of or payment for a
15     health care service or course of treatment. You have the
16     right to have our decision reviewed by an independent
17     review organization not associated with us if our decision
18     involved making a judgment as to the medical necessity,
19     appropriateness, health care setting, level of care, or
20     effectiveness of the health care service or treatment you
21     requested by submitting a written request for an external
22     review to us. Upon receipt of your request an independent
23     review organization registered with the Department of
24     Financial and Professional Regulation, Division of
25     Insurance will be assigned to review our decision.".

 

 

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1         (2) The notice shall also include the appropriate
2     statements and information set forth in subsections (b) and
3     (c) of this Section.
4     (b) The health carrier shall include in the notice required
5 under subsection (a) of this Section for a notice related to an
6 adverse determination, a statement informing the covered
7 person that:
8         (1) if the covered person has a medical condition where
9     the timeframe for completion of an expedited internal
10     review of a grievance involving an adverse determination
11     would seriously jeopardize the life or health of the
12     covered person or would jeopardize the covered person's
13     ability to regain maximum function or if the adverse
14     determination involves a denial of coverage based on a
15     determination that the recommended or requested health
16     care service or treatment is experimental or
17     investigational and the covered person's treating
18     physician certifies in writing that the recommended or
19     requested health care service or treatment that is the
20     subject of the adverse determination would be
21     significantly less effective if not promptly initiated,
22     then the covered person or the covered person's authorized
23     representative may file a request for an expedited external
24     review at the same time the covered person or the covered
25     person's authorized representative files a request for an
26     expedited internal appeal involving an adverse

 

 

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1     determination as set forth by the American Accreditation
2     Health Care Commission. The independent review
3     organization assigned to conduct the expedited external
4     review will determine whether the covered person shall be
5     required to complete the expedited review of the grievance
6     prior to conducting the expedited external review; and
7         (2) the covered person or the covered person's
8     authorized representative may file a grievance under the
9     health carrier's internal grievance process as set forth by
10     the American Accreditation Health Care Commission, but if
11     the health carrier has not issued a written decision to the
12     covered person or the covered person's authorized
13     representative within 30 days following the date the
14     covered person or the covered person's authorized
15     representative files the grievance with the health carrier
16     and the covered person or the covered person's authorized
17     representative has not requested or agreed to a delay, then
18     the covered person or the covered person's authorized
19     representative may file a request for external review and
20     shall be considered to have exhausted the health carrier's
21     internal grievance process.
22     (c) The health carrier shall include in the notice required
23 under subsection (a) of this Section for a notice related to a
24 final adverse determination, a statement informing the covered
25 person that:
26         (1) if the covered person has a medical condition where

 

 

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1     the timeframe for completion of a standard external review
2     would seriously jeopardize the life or health of the
3     covered person or would jeopardize the covered person's
4     ability to regain maximum function, then the covered person
5     or the covered person's authorized representative may file
6     a request for an expedited external review; or
7         (2) if a final adverse determination concerns:
8             (i) an admission, availability of care, continued
9         stay, or health care service for which the covered
10         person received emergency services, but has not been
11         discharged from a facility, then the covered person, or
12         the covered person's authorized representative, may
13         request an expedited external review; or
14             (ii) a denial of coverage based on a determination
15         that the recommended or requested health care service
16         or treatment is experimental or investigational, and
17         the covered person's health care provider certifies in
18         writing that the recommended or requested health care
19         service or treatment that is the subject of the request
20         would be significantly less effective if not promptly
21         initiated, then the covered person or the covered
22         person's authorized representative may request an
23         expedited external review.
24     (d) In addition to the information to be provided pursuant
25 to subsections (a), (b), and (c) of this Section, the health
26 carrier shall include a copy of the description of both the

 

 

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1 required standard and expedited external review procedures.
2 The description shall highlight the external review procedures
3 that give the covered person or the covered person's authorized
4 representative the opportunity to submit additional
5 information, including any forms used to process an external
6 review.
 
7     Section 25. Request for external review. A covered person
8 or the covered person's authorized representative may make a
9 request for a standard external or expedited external review of
10 an adverse determination or final adverse determination.
11 Requests under this Section shall be made directly to the
12 health carrier that made the adverse or final adverse
13 determination. All requests for external review shall be in
14 writing except for requests for expedited external reviews
15 which may me made orally. Health carriers must provide covered
16 persons with forms to request external reviews.
 
17     Section 30. Exhaustion of internal grievance process.
18     (a) Except as provided in item (1) of subsection (b) of
19 Section 20 of this Act, a request for an external review shall
20 not be made until the covered person has exhausted the health
21 carrier's internal grievance process as set forth by the
22 American Accreditation Health Care Commission.
23     (b) A covered person shall be considered to have exhausted
24 the health carrier's internal grievance process for purposes of

 

 

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1 this Section if the covered person or the covered person's
2 authorized representative filed a request for an internal
3 review of an adverse determination pursuant to the American
4 Accreditation Health Care Commission and has not received a
5 written decision on the request from the health carrier within
6 30 days after the request is filed, except to the extent the
7 covered person or the covered person's authorized
8 representative requested or agreed to a delay.
9     (c) Notwithstanding subsection (b) of this Section, a
10 covered person or the covered person's authorized
11 representative may not make a request for an external review of
12 an adverse determination involving a retrospective review
13 determination until the covered person has exhausted the health
14 carrier's internal grievance process.
15     (d) Upon request for an expedited external review pursuant
16 to item (1) of subsection (b) of Section 20 of this Act, the
17 independent review organization conducting the external review
18 shall determine whether the covered person shall be required to
19 complete the expedited review process set forth by the American
20 Accreditation Health Care Commission before it conducts the
21 expedited external review. Upon determination that the covered
22 person must first complete the expedited grievance review
23 process, the independent review organization immediately shall
24 notify the covered person and, if applicable, the covered
25 person's authorized representative of this determination and
26 that it will not proceed with the expedited external review

 

 

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1 until completion of the expedited grievance review process and
2 that covered person's grievance at the completion of the
3 expedited grievance review process remains unresolved.
4     (e) A covered person need not exhaust a heath carrier's
5 internal grievance procedures as set forth by the American
6 Accreditation Health Care Commission, if the health carrier
7 agrees to waive the exhaustion requirement.
 
8     Section 35. Standard external review.
9     (a) Within 4 months after the date of receipt of a notice
10 of an adverse determination or final adverse determination, a
11 covered person or the covered person's authorized
12 representative may file a request for an external review with
13 the health carrier.
14     (b) Within 5 business days following the date of receipt of
15 the external review request, the health carrier shall complete
16 a preliminary review of the request to determine whether:
17         (1) the individual is or was a covered person in the
18     health benefit plan at the time the health care service was
19     requested or at the time the health care service was
20     provided;
21         (2) either of the following situations is applicable:
22             (A) the health care service that is the subject of
23         the adverse determination or the final adverse
24         determination is a covered service under the covered
25         person's health benefit plan, but the health carrier

 

 

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1         has determined that the health care service is not
2         covered because it does not meet the health carrier's
3         requirements for medical necessity, appropriateness,
4         health care setting, level of care, or effectiveness;
5         or
6             (B) the recommended or requested health care
7         service or treatment that is the subject of the adverse
8         determination or final adverse determination is a
9         covered benefit under the covered person's health
10         benefit plan except for the health carrier's
11         determination that the service or treatment is
12         experimental or investigational for a particular
13         medical condition and is not explicitly listed as an
14         excluded benefit under the covered person's health
15         benefit plan with the health carrier;
16         (3) the covered person's treating physician has
17     certified that one of the following situations is
18     applicable:
19             (A) standard health care services or treatments
20         have not been effective in improving the condition of
21         the covered person;
22             (B) standard health care services or treatments
23         are not medically appropriate for the covered person;
24         or
25             (C) there is no available standard health care
26         service or treatment covered by the health carrier that

 

 

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1         is more beneficial than the recommended or requested
2         health care service or treatment described in item (4)
3         of this subsection (b);
4         (4) the covered person's treating physician:
5             (A) has recommended a health care service or
6         treatment that the physician certifies, in writing, is
7         likely to be more beneficial to the covered person, in
8         the physician's opinion, than any available standard
9         health care service or treatment; or
10             (B) who is a licensed, board certified, or board
11         eligible physician qualified to practice in the area of
12         medicine appropriate to treat the covered person's
13         condition, has certified in writing that
14         scientifically valid studies using accepted protocols
15         demonstrate that the health care service or treatment
16         requested by the covered person that is the subject of
17         the adverse determination or final adverse
18         determination is likely to be more beneficial to the
19         covered person than any available standard health care
20         services or treatments;
21         (5) the covered person has exhausted the health
22     carrier's internal grievance process as set forth in
23     Section 30 of this Act; and
24         (6) the covered person has provided all the information
25     and forms required to process an external review as
26     specified in this Act.

 

 

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1     (c) Within one business day after completion of the
2 preliminary review, the health carrier shall notify the covered
3 person and, if applicable, the covered person's authorized
4 representative in writing whether the request is complete and
5 eligible for external review. If the request:
6         (1) is not complete, the health carrier shall inform
7     the covered person and, if applicable, the covered person's
8     authorized representative in writing and include in the
9     notice what information or materials are required by this
10     Act to make the request complete; or
11         (2) is not eligible for external review, the health
12     carrier shall inform the covered person and, if applicable,
13     the covered person's authorized representative in writing
14     and include in the notice the reasons for its
15     ineligibility.
16     The notice of initial determination of ineligibility shall
17 include a statement informing the covered person and, if
18 applicable, the covered person's authorized representative
19 that a health carrier's initial determination that the external
20 review request is ineligible for review may be appealed to the
21 Director by filing a complaint with the Director.
22     Notwithstanding a health carrier's initial determination
23 that the request is ineligible for external review, the
24 Director may determine that a request is eligible for external
25 review and require that it be referred for external review. In
26 making such determination, the Director's decision shall be in

 

 

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1 accordance with the terms of the covered person's health
2 benefit plan and shall be subject to all applicable provisions
3 of this Act.
4     (d) Whenever a request is eligible for external review the
5 health carrier shall, within 5 business days:
6         (1) assign an independent review organization from the
7     list of approved independent review organizations compiled
8     and maintained by the Director; and
9         (2) notify in writing the covered person and, if
10     applicable, the covered person's authorized representative
11     of the request's eligibility and acceptance for external
12     review and the name of the independent review organization.
13     The health carrier shall include in the notice provided to
14 the covered person and, if applicable, the covered person's
15 authorized representative a statement that the covered person
16 or the covered person's authorized representative may, within 5
17 business days following the date of receipt of the notice
18 provided pursuant to item (2) of this subsection (d), submit in
19 writing to the assigned independent review organization
20 additional information that the independent review
21 organization shall consider when conducting the external
22 review. The independent review organization is not required to,
23 but may, accept and consider additional information submitted
24 after 5 business days.
25     (e) The assignment of an approved independent review
26 organization to conduct an external review in accordance with

 

 

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1 this Section shall be done on a random basis among those
2 approved independent review organizations qualified to conduct
3 external review except for instances of conflict of interest
4 concerns pursuant to this Act.
5     (f) Upon assignment of an independent review organization,
6 the health carrier or its designee utilization review
7 organization shall, within 5 business days, provide to the
8 assigned independent review organization the documents and any
9 information considered in making the adverse determination or
10 final adverse determination; in such cases, the following
11 provisions shall apply:
12         (1) Except as provided in item (2) of this subsection
13     (f), failure by the health carrier or its utilization
14     review organization to provide the documents and
15     information within the specified time frame shall not delay
16     the conduct of the external review.
17         (2) If the health carrier or its utilization review
18     organization fails to provide the documents and
19     information within the specified time frame, the assigned
20     independent review organization may terminate the external
21     review and make a decision to reverse the adverse
22     determination or final adverse determination.
23         (3) Within one business day after making the decision
24     to terminate the external review and make a decision to
25     reverse the adverse determination or final adverse
26     determination under item (2) of this subsection (f), the

 

 

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1     independent review organization shall notify the health
2     carrier, the covered person and, if applicable, the covered
3     person's authorized representative, of its decision to
4     reverse the adverse determination.
5     (g) Upon receipt of the information from the health carrier
6 or its utilization review organization, the assigned
7 independent review organization shall review all of the
8 information and documents and any other information submitted
9 in writing to the independent review organization by the
10 covered person and the covered person's authorized
11 representative.
12     (h) Upon receipt of any information submitted by the
13 covered person or the covered person's authorized
14 representative, the independent review organization shall
15 forward the information to the health carrier within 1 business
16 day.
17         (1) Upon receipt of the information, if any, the health
18     carrier may reconsider its adverse determination or final
19     adverse determination that is the subject of the external
20     review.
21         (2) Reconsideration by the health carrier of its
22     adverse determination or final adverse determination shall
23     not delay or terminate the external review.
24         (3) The external review may only be terminated if the
25     health carrier decides, upon completion of its
26     reconsideration, to reverse its adverse determination or

 

 

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1     final adverse determination and provide coverage or
2     payment for the health care service that is the subject of
3     the adverse determination or final adverse determination.
4     In such cases, the following provisions shall apply:
5             (A) Within one business day after making the
6         decision to reverse its adverse determination or final
7         adverse determination, the health carrier shall notify
8         the covered person, if applicable, the covered
9         person's authorized representative, and the assigned
10         independent review organization in writing of its
11         decision.
12             (B) Upon notice from the health carrier that the
13         health carrier has made a decision to reverse its
14         adverse determination or final adverse determination,
15         the assigned independent review organization shall
16         terminate the external review.
17     (i) In addition to the documents and information provided
18 by the health carrier or its utilization review organization
19 and the covered person and the covered person's authorized
20 representative, if any, the independent review organization,
21 to the extent the information or documents are available and
22 the independent review organization considers them
23 appropriate, shall consider the following in reaching a
24 decision:
25         (1) for an adverse determination or final adverse
26     determination:

 

 

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1             (A) the covered person's pertinent medical
2         records;
3             (B) the covered person's health care provider's
4         recommendation;
5             (C) consulting reports from appropriate health
6         care providers and other documents submitted by the
7         health carrier, the covered person, the covered
8         person's authorized representative, or the covered
9         person's treating provider;
10             (D) the terms of coverage under the covered
11         person's health benefit plan with the health carrier to
12         ensure that the independent review organization's
13         decision is not contrary to the terms of coverage under
14         the covered person's health benefit plan with the
15         health carrier;
16             (E) the most appropriate practice guidelines,
17         which shall include applicable evidence-based
18         standards and may include any other practice
19         guidelines developed by the federal government,
20         national or professional medical societies, boards,
21         and associations;
22             (F) any applicable clinical review criteria
23         developed and used by the health carrier or its
24         designee utilization review organization; and
25             (G) the opinion of the independent review
26         organization's clinical reviewer or reviewers after

 

 

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1         considering paragraphs (A) through (G) of this item (1)
2         of this subsection (i) to the extent the information or
3         documents are available and the clinical reviewer or
4         reviewers considers the information or documents
5         appropriate;
6         (2) for an adverse determination or final adverse
7     determination that involves a denial of coverage based on a
8     determination that the health care service or treatment
9     recommended or requested is experimental or
10     investigational:
11             (A) the covered person's pertinent medical
12         records;
13             (B) the covered person's health care provider's
14         recommendation;
15             (C) consulting reports from appropriate health
16         care providers and other documents submitted by the
17         health carrier, the covered person, the covered
18         person's authorized representative, or the covered
19         person's treating physician or health care
20         professional;
21             (D) the terms of coverage under the covered
22         person's health benefit plan with the health carrier to
23         ensure that, but for the health carrier's
24         determination that the recommended or requested health
25         care service or treatment that is the subject of the
26         opinion is experimental or investigational, the

 

 

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1         independent review organization's opinion is not
2         contrary to the terms of coverage under the covered
3         person's health benefit plan with the health carrier;
4         and
5             (E) whether and to what extent:
6                 (i) the recommended or requested health care
7             service or treatment has been approved by the
8             federal Food and Drug Administration, if
9             applicable, for the condition; or
10                 (ii) medical or scientific evidence or
11             evidence-based standards demonstrate that the
12             expected benefits of the recommended or requested
13             health care service or treatment is more likely
14             than not to be beneficial to the covered person
15             than any available standard health care service or
16             treatment and the adverse risks of the recommended
17             or requested health care service or treatment
18             would not be substantially increased over those of
19             available standard health care services or
20             treatments; or
21         (3) except for an expedited external review, for an
22     adverse determination or final adverse determination that
23     involves a denial of coverage based on a determination that
24     the health care service or treatment recommended or
25     requested is experimental or investigational, each
26     clinical reviewer selected by the independent review

 

 

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1     organization shall provide its opinion to the independent
2     review organization in writing and include the following
3     information:
4             (A) a description of the covered person's medical
5         condition;
6             (B) a description of the indicators relevant to
7         determining whether there is sufficient evidence to
8         demonstrate that the recommended or requested health
9         care service or treatment is more likely than not to be
10         beneficial to the covered person than any available
11         standard health care services or treatments and the
12         adverse risks of the recommended or requested health
13         care service or treatment would not be substantially
14         increased over those of available standard health care
15         services or treatments;
16             (C) a description and analysis of any medical or
17         scientific evidence considered in reaching the
18         opinion;
19             (D) a description and analysis of any
20         evidence-based standard; and
21             (E) information on whether the reviewer's
22         rationale for the opinion is based on paragraphs (i) or
23         (ii) of subitem (E) of item (2) of this subsection (i).
24     (j) Within 5 days after the date of receipt of all
25 necessary information, the assigned independent review
26 organization shall provide written notice of its decision to

 

 

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1 uphold or reverse the adverse determination or the final
2 adverse determination to the health carrier, the covered person
3 and, if applicable, the covered person's authorized
4 representative. In reaching a decision, the assigned
5 independent review organization is not bound by any decisions
6 or conclusions reached during the health carrier's utilization
7 review process as set forth by the American Accreditation
8 Health Care Commission. In such cases, the following provisions
9 shall apply:
10         (1) The independent review organization shall include
11     in the notice:
12             (A) a general description of the reason for the
13         request for external review;
14             (B) the date the independent review organization
15         received the assignment from the health carrier to
16         conduct the external review;
17             (C) the time period during which the external
18         review was conducted;
19             (D) references to the evidence or documentation,
20         including the evidence-based standards, considered in
21         reaching its decision.
22             (E) the date of its decision; and
23             (F) the principal reason or reasons for its
24         decision, including what applicable, if any,
25         evidence-based standards that were a basis for its
26         decision.

 

 

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1         (2) For reviews of experimental or investigational
2     treatments, the notice shall include the following
3     information:
4             (A) a general description of the reason for the
5         request for external review;
6             (B) the written opinion of each clinical reviewer,
7         including the recommendation of each clinical reviewer
8         as to whether the recommended or requested health care
9         service or treatment should be covered and the
10         rationale for the reviewer's recommendation;
11             (C) the date that the independent review
12         organization received assignment from the health
13         carrier to conduct the external review;
14             (D) the time period during which the external
15         review was conducted; and
16             (E) the principal reason or reasons for its
17         decision.
18         (3) Upon receipt of a notice of a decision reversing
19     the adverse determination or final adverse determination,
20     the health carrier immediately shall approve the coverage
21     that was the subject of the adverse determination or final
22     adverse determination.
 
23     Section 40. Expedited external review.
24     (a) A covered person or a covered person's authorized
25 representative may file a request for an expedited external

 

 

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1 review with the health carrier either orally or in writing at
2 the time the covered person receives:
3         (1) an adverse determination, if:
4             (A) the adverse determination involves a medical
5         condition of the covered person for which the timeframe
6         for completion of an expedited internal review of a
7         grievance involving an adverse determination as set
8         forth by the American Accreditation Health Care
9         Commission would seriously jeopardize the life or
10         health of the covered person or would jeopardize the
11         covered person's ability to regain maximum function;
12         and
13             (B) the covered person or the covered person's
14         authorized representative has filed a request for an
15         expedited review of a grievance involving an adverse
16         determination as set forth by the American
17         Accreditation Health Care Commission; or
18         (2) a final adverse determination, if:
19             (A) the covered person has a medical condition
20         where the timeframe for completion of a standard
21         external review would seriously jeopardize the life or
22         health of the covered person or would jeopardize the
23         covered person's ability to regain maximum function;
24         or
25             (B) the final adverse determination concerns an
26         admission, availability of care, continued stay, or

 

 

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1         health care service for which the covered person
2         received emergency services but has not been
3         discharged from a facility.
4     (b) Upon receipt of a request for an expedited external
5 review as provided in Section 20 of this Act, the health
6 carrier shall determine whether the request meets the
7 reviewability requirements set forth in subsection (b) of
8 Section 35 of this Act. The health carrier shall immediately
9 notify the covered person and, if applicable, the covered
10 person's authorized representative of its eligibility
11 determination. The notice of initial determination shall
12 include a statement informing the covered person and, if
13 applicable, the covered person's authorized representative
14 that a health carrier's initial determination that an external
15 review request is ineligible for review may be appealed to the
16 Director.
17     (c) The Director may determine that a request is eligible
18 for external review under subsection (b) of Section 35 of this
19 Act, notwithstanding a health carrier's initial determination
20 that the request is ineligible and require that it be referred
21 for external review. In making a determination, the Director's
22 decision shall be made in accordance with the terms of the
23 covered person's health benefit plan and shall be subject to
24 all applicable provisions of this Act.
25     (d) Whenever a request is eligible for external review, the
26 health carrier shall immediately assign an independent review

 

 

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1 organization from the list of approved independent review
2 organizations compiled and maintained by the Director to
3 conduct the expedited review. In such cases, the following
4 provisions shall apply:
5         (1) The assignment by the health carrier of an approved
6     independent review organization to conduct an external
7     review in accordance with this Section shall be done on a
8     random basis among those approved independent review
9     organizations except as may be prohibited by conflict of
10     interest concerns pursuant to Section 60 of this Act.
11         (2) Immediately upon assigning an independent review
12     organization to perform an expedited external review, but
13     in no case less than 24 hours after assigning the
14     independent review organization, the health carrier or its
15     designee utilization review organization shall provide or
16     transmit all necessary documents and information
17     considered in making the final adverse determination to the
18     assigned independent review organization electronically or
19     by telephone or facsimile or any other available
20     expeditious method.
21         (3) If the health carrier or its utilization review
22     organization fails to provide the documents and
23     information within the specified time frame, the assigned
24     independent review organization may terminate the external
25     review and make a decision to reverse the adverse
26     determination or final adverse determination.

 

 

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1         (4) Within one business day after making the decision
2     to terminate the external review and make a decision to
3     reverse the adverse determination or final adverse
4     determination under item (2) of this subsection (d), the
5     independent review organization shall notify the health
6     carrier, the covered person and, if applicable, the covered
7     person's authorized representative of its decision to
8     reverse the adverse determination.
9     (e) In addition to the documents and information provided
10 by the health carrier or its utilization review organization
11 and any documents and information provided by the covered
12 person and the covered person's authorized representative, the
13 independent review organization shall consider the following
14 in reaching a decision:
15         (1) for an adverse determination or final adverse
16     determination, the provisions included in subitems (A)
17     through (G) of item (1) of subsection (i) of Section 35 of
18     this Act; or
19         (2) for an adverse determination or final adverse
20     determination that involves a denial of coverage based on a
21     determination that the health care service or treatment
22     recommended or requested is experimental or
23     investigational, the provisions included in subitems (A)
24     through (E) of item (2) of subsection (i) of Section 35 of
25     this Act.
26     (f) As expeditiously as the covered person's medical

 

 

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1 condition or circumstances requires, but in no event more than
2 72 hours after the receipt of all pertinent information, the
3 assigned independent review organization shall:
4         (1) make a decision to uphold or reverse the final
5     adverse determination; and
6         (2) notify the health carrier, the covered person, the
7     covered person's health care provider, and if applicable,
8     the covered person's authorized representative, of the
9     decision.
10     (g) In reaching a decision, the assigned independent review
11 organization is not bound by any decisions or conclusions
12 reached during the health carrier's utilization review process
13 or the health carrier's internal grievance process as set forth
14 by the American Accreditation Health Care Commission.
15     (h) Upon receipt of notice of a decision reversing the
16 final adverse determination, the health carrier shall
17 immediately approve the coverage that was the subject of the
18 final adverse determination. Within 48 hours after the date of
19 providing the notice required in this subsection (h), the
20 assigned independent review organization shall provide written
21 confirmation of the decision to the health carrier, the covered
22 person, and if applicable, the covered person's authorized
23 representative including the information set forth in
24 subsection (j) of Section 35 of this Act as applicable.
25     (i) An expedited external review may not be provided for
26 retrospective adverse or final adverse determinations.
 

 

 

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1     Section 45. Binding nature of external review decision. An
2 external review decision is binding on the health carrier. An
3 external review decision is binding on the covered person
4 except to the extent the covered person has other remedies
5 available under applicable federal or State law. A covered
6 person or the covered person's authorized representative may
7 not file a subsequent request for external review involving the
8 same adverse determination or final adverse determination for
9 which the covered person has already received an external
10 review decision pursuant to this Act.
 
11     Section 50. Approval of independent review organizations.
12     (a) The Director shall approve independent review
13 organizations eligible to be assigned to conduct external
14 reviews under this Act.
15     (b) In order to be eligible for approval by the Director
16 under this Section to conduct external reviews under this Act
17 an independent review organization:
18         (1) except as otherwise provided in this Section, shall
19     be accredited by a nationally recognized private
20     accrediting entity that the Director has determined has
21     independent review organization accreditation standards
22     that are equivalent to or exceed the minimum qualifications
23     for independent review; and
24         (2) shall submit an application for approval in

 

 

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1     accordance with subsection (d) of this Section.
2     (c) The Director shall develop an application form for
3 initially approving and for reapproving independent review
4 organizations to conduct external reviews.
5     (d) Any independent review organization wishing to be
6 approved to conduct external reviews under this Act shall
7 submit the application form and include with the form all
8 documentation and information necessary for the Director to
9 determine if the independent review organization satisfies the
10 minimum qualifications established under this Act. The
11 Director may:
12         (1) approve independent review organizations that are
13     not accredited by a nationally recognized private
14     accrediting entity if there are no acceptable nationally
15     recognized private accrediting entities providing
16     independent review organization accreditation; and
17         (2) by rule establish an application fee that
18     independent review organizations shall submit to the
19     Director with an application for approval and renewing.
20     (e) An approval is effective for 2 years, unless the
21 Director determines before its expiration that the independent
22 review organization is not satisfying the minimum
23 qualifications established under this Act.
24     (f) Whenever the Director determines that an independent
25 review organization has lost its accreditation or no longer
26 satisfies the minimum requirements established under this Act,

 

 

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1 the Director shall terminate the approval of the independent
2 review organization and remove the independent review
3 organization from the list of independent review organizations
4 approved to conduct external reviews under this Act that is
5 maintained by the Director.
6     (g) The Director shall maintain and periodically update a
7 list of approved independent review organizations.
8     (h) The Director may promulgate regulations to carry out
9 the provisions of this Section.
 
10     Section 55. Minimum qualifications for independent review
11 organizations.
12     (a) To be approved to conduct external reviews, an
13 independent review organization shall have and maintain
14 written policies and procedures that govern all aspects of both
15 the standard external review process and the expedited external
16 review process set forth in this Act that include, at a
17 minimum:
18         (1) a quality assurance mechanism that ensures that:
19             (A) external reviews are conducted within the
20         specified time frames and required notices are
21         provided in a timely manner;
22             (B) selection of qualified and impartial clinical
23         reviewers to conduct external reviews on behalf of the
24         independent review organization and suitable matching
25         of reviewers to specific cases and that the independent

 

 

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1         review organization employs or contracts with an
2         adequate number of clinical reviewers to meet this
3         objective;
4             (C) the health carrier, the covered person, and the
5         covered person's authorized representative shall not
6         choose or control the choice of the physicians or other
7         health care professionals to be selected to conduct the
8         external review;
9             (D) confidentiality of medical and treatment
10         records and clinical review criteria; and
11             (E) any person employed by or under contract with
12         the independent review organization adheres to the
13         requirements of this Act;
14         (2) a toll-free telephone service operating on a
15     24-hour-day, 7-day-a-week basis that accepts, receives,
16     and records information related to external reviews and
17     provides appropriate instructions; and
18         (3) an agreement to maintain and provide to the
19     Director the information set out in Section 70 of this Act.
20     (b) All clinical reviewers assigned by an independent
21 review organization to conduct external reviews shall be
22 physicians or other appropriate health care providers who meet
23 the following minimum qualifications:
24         (1) be an expert in the treatment of the covered
25     person's medical condition that is the subject of the
26     external review;

 

 

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1         (2) be knowledgeable about the recommended health care
2     service or treatment through recent or current actual
3     clinical experience treating patients with the same or
4     similar medical condition of the covered person;
5         (3) hold a non-restricted license in a state of the
6     United States and, for physicians, a current certification
7     by a recognized American medical specialty board in the
8     area or areas appropriate to the subject of the external
9     review;
10         (4) have no history of disciplinary actions or
11     sanctions, including loss of staff privileges or
12     participation restrictions, that have been taken or are
13     pending by any hospital, governmental agency or unit, or
14     regulatory body that raise a substantial question as to the
15     clinical reviewer's physical, mental, or professional
16     competence or moral character; and
17         (5) for purposes of conducting an external review of
18     experimental or investigational treatment adverse
19     determinations, through clinical experience in the past 3
20     years, be an expert in the treatment of the covered
21     person's condition and knowledgeable about the recommended
22     or requested health care service or treatment; neither the
23     covered person, the covered person's authorized
24     representative, if applicable, nor the health carrier
25     shall choose or control the choice of the physicians or
26     other health care professionals selected to conduct the

 

 

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1     external review.
2     (c) In addition to the requirements set forth in subsection
3 (a), an independent review organization may not own or control,
4 be a subsidiary of, or in any way be owned, or controlled by,
5 or exercise control with a health benefit plan, a national,
6 State, or local trade association of health benefit plans, or a
7 national, State, or local trade association of health care
8 providers.
9     (d) Conflicts of interest prohibited. In addition to the
10 requirements set forth in subsections (a), (b), and (c) of this
11 Section, to be approved pursuant to this Act to conduct an
12 external review of a specified case, neither the independent
13 review organization selected to conduct the external review nor
14 any clinical reviewer assigned by the independent organization
15 to conduct the external review may have a material
16 professional, familial or financial conflict of interest with
17 any of the following:
18         (1) the health carrier that is the subject of the
19     external review;
20         (2) the covered person whose treatment is the subject
21     of the external review or the covered person's authorized
22     representative;
23         (3) any officer, director or management employee of the
24     health carrier that is the subject of the external review;
25         (4) the health care provider, the health care
26     provider's medical group or independent practice

 

 

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1     association recommending the health care service or
2     treatment that is the subject of the external review;
3         (5) the facility at which the recommended health care
4     service or treatment would be provided; or
5         (6) the developer or manufacturer of the principal
6     drug, device, procedure, or other therapy being
7     recommended for the covered person whose treatment is the
8     subject of the external review.
9     (e) An independent review organization that is accredited
10 by a nationally recognized private accrediting entity that has
11 independent review accreditation standards that the Director
12 has determined are equivalent to or exceed the minimum
13 qualifications of this Section shall be presumed to be in
14 compliance with this Section and shall be eligible for approval
15 under this Section.
16     (f) An independent review organization shall be unbiased.
17 An independent review organization shall establish and
18 maintain written procedures to ensure that it is unbiased in
19 addition to any other procedures required under this Section.
 
20     Section 60. Hold harmless for independent review
21 organizations. No independent review organization or clinical
22 reviewer working on behalf of an independent review
23 organization or an employee, agent or contractor of an
24 independent review organization shall be liable for damages to
25 any person for any opinions rendered or acts or omissions

 

 

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1 performed within the scope of the organization's or person's
2 duties under the law during or upon completion of an external
3 review conducted pursuant to this Act, unless the opinion was
4 rendered or act or omission performed in bad faith or involved
5 gross negligence.
 
6     Section 65. External review reporting requirements.
7     (a) Each health carrier shall maintain written records in
8 the aggregate on all requests for external review for each
9 calendar year and submit a report to the Director in the format
10 specified by the Director by March 1 of each year.
11     (b) The report shall include in the aggregate:
12         (1) the total number of requests for external review;
13         (2) the total number of requests for expedited external
14     review;
15         (3) the total number of requests for external review
16     denied;
17         (4) the number of requests for external review
18     resolved, including:
19             (A) the number of requests for external review
20         resolved upholding the adverse determination or final
21         adverse determination;
22             (B) the number of requests for external review
23         resolved reversing the adverse determination or final
24         adverse determination;
25             (C) the number of requests for expedited external

 

 

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1         review resolved upholding the adverse determination or
2         final adverse determination; and
3             (D) the number of requests for expedited external
4         review resolved reversing the adverse determination or
5         final adverse determination;
6         (5) the average length of time for resolution for an
7     external review;
8         (6) the average length of time for resolution for an
9     expedited external review;
10         (7) a summary of the types of coverages or cases for
11     which an external review was sought, as specified below:
12             (A) denial of care or treatment (dissatisfaction
13         regarding prospective non-authorization of a request
14         for care or treatment recommended by a provider
15         excluding diagnostic procedures and referral requests;
16         partial approvals and care terminations are also
17         considered to be denials);
18             (B) denial of diagnostic procedure
19         (dissatisfaction regarding prospective
20         non-authorization of a request for a diagnostic
21         procedure recommended by a provider; partial approvals
22         are also considered to be denials);
23             (C) denial of referral request (dissatisfaction
24         regarding non-authorization of a request for a
25         referral to another provider recommended by a PCP);
26             (D) claims and utilization review (dissatisfaction

 

 

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1         regarding the concurrent or retrospective evaluation
2         of the coverage, medical necessity, efficiency or
3         appropriateness of health care services or treatment
4         plans; prospective "Denials of care or treatment,"
5         "Denials of diagnostic procedures" and "Denials of
6         referral requests" should not be classified in this
7         category, but the appropriate one above);
8         (8) the number of external reviews that were terminated
9     as the result of a reconsideration by the health carrier of
10     its adverse determination or final adverse determination
11     after the receipt of additional information from the
12     covered person or the covered person's authorized
13     representative; and
14         (9) any other information the Director may request or
15     require.
 
16     Section 70. Funding of external review. The health carrier
17 shall be solely responsible for paying the cost of external
18 reviews conducted by independent review organizations.
 
19     Section 75. Disclosure requirements.
20     (a) Each health carrier shall include a description of the
21 external review procedures in, or attached to, the policy,
22 certificate, membership booklet, and outline of coverage or
23 other evidence of coverage it provides to covered persons.
24     (b) The description required under subsection (a) of this

 

 

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1 Section shall include a statement that informs the covered
2 person of the right of the covered person to file a request for
3 an external review of an adverse determination or final adverse
4 determination with the health carrier. The statement shall
5 explain that external review is available when the adverse
6 determination or final adverse determination involves an issue
7 of medical necessity, appropriateness, health care setting,
8 level of care, or effectiveness. The statement shall include
9 the toll-free telephone number and address of the Office of
10 Consumer Health Insurance within the Division of Insurance.
 
11     Section 97. Severability. The provisions of this Act are
12 severable under Section 1.31 of the Statute on Statutes.
 
13     Section 99. Effective date. This Act takes effect January
14 1, 2010.".