Illinois General Assembly - Full Text of HB4223
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Full Text of HB4223  95th General Assembly


Rep. Mary E. Flowers

Filed: 3/4/2008





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2     AMENDMENT NO. ______. Amend House Bill 4223, on page 4,
3 line 17, by deleting "or"; and
4 on page 4, line 20, after "health", by inserting ", or (iii)
5 nonrenewal or termination of a policy or plan"; and
6 on page 15, immediately below line 8, by inserting the
7 following:
8     "Section 37. The Managed Care Reform and Patient Rights Act
9 is amended by changing Section 45 as follows:
10     (215 ILCS 134/45)
11     Sec. 45. Health care services appeals, complaints, and
12 external independent reviews.
13     (a) A health care plan shall establish and maintain an
14 appeals procedure as outlined in this Act. Compliance with this



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1 Act's appeals procedures shall satisfy a health care plan's
2 obligation to provide appeal procedures under any other State
3 law or rules. All appeals of a health care plan's
4 administrative determinations and complaints regarding its
5 administrative decisions shall be handled as required under
6 Section 50.
7     (b) When an appeal concerns a decision or action by a
8 health care plan, its employees, or its subcontractors that
9 relates to (i) health care services, including, but not limited
10 to, procedures or treatments, for an enrollee with an ongoing
11 course of treatment ordered by a health care provider, the
12 denial of which could significantly increase the risk to an
13 enrollee's health, or (ii) a treatment referral, service,
14 procedure, or other health care service, the denial of which
15 could significantly increase the risk to an enrollee's health,
16 or (iii) nonrenewal or termination of a plan, the health care
17 plan must allow for the filing of an appeal either orally or in
18 writing. Upon submission of the appeal, a health care plan must
19 notify the party filing the appeal, as soon as possible, but in
20 no event more than 24 hours after the submission of the appeal,
21 of all information that the plan requires to evaluate the
22 appeal. The health care plan shall render a decision on the
23 appeal within 24 hours after receipt of the required
24 information. The health care plan shall notify the party filing
25 the appeal and the enrollee, enrollee's primary care physician,
26 and any health care provider who recommended the health care



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1 service involved in the appeal of its decision orally
2 followed-up by a written notice of the determination.
3     (c) For all appeals related to health care services
4 including, but not limited to, procedures or treatments for an
5 enrollee and not covered by subsection (b) above, the health
6 care plan shall establish a procedure for the filing of such
7 appeals. Upon submission of an appeal under this subsection, a
8 health care plan must notify the party filing an appeal, within
9 3 business days, of all information that the plan requires to
10 evaluate the appeal. The health care plan shall render a
11 decision on the appeal within 15 business days after receipt of
12 the required information. The health care plan shall notify the
13 party filing the appeal, the enrollee, the enrollee's primary
14 care physician, and any health care provider who recommended
15 the health care service involved in the appeal orally of its
16 decision followed-up by a written notice of the determination.
17     (d) An appeal under subsection (b) or (c) may be filed by
18 the enrollee, the enrollee's designee or guardian, the
19 enrollee's primary care physician, or the enrollee's health
20 care provider. A health care plan shall designate a clinical
21 peer to review appeals, because these appeals pertain to
22 medical or clinical matters and such an appeal must be reviewed
23 by an appropriate health care professional. No one reviewing an
24 appeal may have had any involvement in the initial
25 determination that is the subject of the appeal. The written
26 notice of determination required under subsections (b) and (c)



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1 shall include (i) clear and detailed reasons for the
2 determination, (ii) the medical or clinical criteria for the
3 determination, which shall be based upon sound clinical
4 evidence and reviewed on a periodic basis, and (iii) in the
5 case of an adverse determination, the procedures for requesting
6 an external independent review under subsection (f).
7     (e) If an appeal filed under subsection (b) or (c) is
8 denied for a reason including, but not limited to, the service,
9 procedure, or treatment is not viewed as medically necessary,
10 denial of specific tests or procedures, denial of referral to
11 specialist physicians or denial of hospitalization requests or
12 length of stay requests, any involved party may request an
13 external independent review under subsection (f) of the adverse
14 determination.
15     (f) External independent review.
16         (1) The party seeking an external independent review
17     shall so notify the health care plan. The health care plan
18     shall seek to resolve all external independent reviews in
19     the most expeditious manner and shall make a determination
20     and provide notice of the determination no more than 24
21     hours after the receipt of all necessary information when a
22     delay would significantly increase the risk to an
23     enrollee's health or when extended health care services for
24     an enrollee undergoing a course of treatment prescribed by
25     a health care provider are at issue.
26         (2) Within 30 days after the enrollee receives written



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1     notice of an adverse determination, if the enrollee decides
2     to initiate an external independent review, the enrollee
3     shall send to the health care plan a written request for an
4     external independent review, including any information or
5     documentation to support the enrollee's request for the
6     covered service or claim for a covered service.
7         (3) Within 30 days after the health care plan receives
8     a request for an external independent review from an
9     enrollee, the health care plan shall:
10             (A) provide a mechanism for joint selection of an
11         external independent reviewer by the enrollee, the
12         enrollee's physician or other health care provider,
13         and the health care plan; and
14             (B) forward to the independent reviewer all
15         medical records and supporting documentation
16         pertaining to the case, a summary description of the
17         applicable issues including a statement of the health
18         care plan's decision, the criteria used, and the
19         medical and clinical reasons for that decision.
20         (4) Within 5 days after receipt of all necessary
21     information, the independent reviewer shall evaluate and
22     analyze the case and render a decision that is based on
23     whether or not the health care service or claim for the
24     health care service is medically appropriate. The decision
25     by the independent reviewer is final. If the external
26     independent reviewer determines the health care service to



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1     be medically appropriate, the health care plan shall pay
2     for the health care service.
3         (5) The health care plan shall be solely responsible
4     for paying the fees of the external independent reviewer
5     who is selected to perform the review.
6         (6) An external independent reviewer who acts in good
7     faith shall have immunity from any civil or criminal
8     liability or professional discipline as a result of acts or
9     omissions with respect to any external independent review,
10     unless the acts or omissions constitute wilful and wanton
11     misconduct. For purposes of any proceeding, the good faith
12     of the person participating shall be presumed.
13         (7) Future contractual or employment action by the
14     health care plan regarding the patient's physician or other
15     health care provider shall not be based solely on the
16     physician's or other health care provider's participation
17     in this procedure.
18         (8) For the purposes of this Section, an external
19     independent reviewer shall:
20             (A) be a clinical peer;
21             (B) have no direct financial interest in
22         connection with the case; and
23             (C) have not been informed of the specific identity
24         of the enrollee.
25     (g) Nothing in this Section shall be construed to require a
26 health care plan to pay for a health care service not covered



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1 under the enrollee's certificate of coverage or policy.
2     (h) Notwithstanding any other rulemaking authority that
3 may exist, neither the Governor nor any agency or agency head
4 under the jurisdiction of the Governor has any authority to
5 make or promulgate rules to implement or enforce the provisions
6 of this amendatory Act of the 95th General Assembly. If,
7 however, the Governor believes that rules are necessary to
8 implement or enforce the provisions of this amendatory Act of
9 the 95th General Assembly, the Governor may suggest rules to
10 the General Assembly by filing them with the Clerk of the House
11 and the Secretary of the Senate and by requesting that the
12 General Assembly authorize such rulemaking by law, enact those
13 suggested rules into law, or take any other appropriate action
14 in the General Assembly's discretion. Nothing contained in this
15 amendatory Act of the 95th General Assembly shall be
16 interpreted to grant rulemaking authority under any other
17 Illinois statute where such authority is not otherwise
18 explicitly given. For the purposes of this amendatory Act of
19 the 95th General Assembly, "rules" is given the meaning
20 contained in Section 1-70 of the Illinois Administrative
21 Procedure Act, and "agency" and "agency head" are given the
22 meanings contained in Sections 1-20 and 1-25 of the Illinois
23 Administrative Procedure Act to the extent that such
24 definitions apply to agencies or agency heads under the
25 jurisdiction of the Governor.
26 (Source: P.A. 91-617, eff. 1-1-00.)".