Full Text of HB0224 97th General Assembly
HB0224enr 97TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning insurance.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Health Carrier External Review Act is | 5 | | amended by changing Sections 10, 20, 25, 30, 35, 40, 55, 65, | 6 | | and 75 and by adding Sections 42 and 80 as follows: | 7 | | (215 ILCS 180/10)
| 8 | | Sec. 10. Definitions. For the purposes of this Act: | 9 | | "Adverse determination" means: | 10 | | (1) a determination by a health carrier or its designee | 11 | | utilization review organization that, based upon the | 12 | | information provided, a request for a benefit under the | 13 | | health carrier's health benefit plan upon application of | 14 | | any utilization review technique does not meet the health | 15 | | carrier's requirements for medical necessity, | 16 | | appropriateness, health care setting, level of care, or | 17 | | effectiveness or is determined to be experimental or | 18 | | investigational and the requested benefit is therefore | 19 | | denied, reduced, or terminated or payment is not provided | 20 | | or made, in whole or in part, for the benefit; | 21 | | (2) the denial, reduction, or termination of or failure | 22 | | to provide or make payment, in whole or in part, for a | 23 | | benefit based on a determination by a health carrier or its |
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| 1 | | designee utilization review organization that a | 2 | | preexisting condition was present before the effective | 3 | | date of coverage; or | 4 | | (3) a recission of coverage determination, which does | 5 | | not include a cancellation or discontinuance of coverage | 6 | | that is attributable to a failure to timely pay required | 7 | | premiums or contributions towards the cost of coverage. | 8 | | means a determination by a health carrier or its designee | 9 | | utilization review organization that an admission, | 10 | | availability of care, continued stay, or other health care | 11 | | service that is a covered benefit has been reviewed and, | 12 | | based upon the information provided, does not meet the | 13 | | health carrier's requirements for medical necessity, | 14 | | appropriateness, health care setting, level of care, or | 15 | | effectiveness, and the requested service or payment for the | 16 | | service is therefore denied, reduced, or terminated. | 17 | | "Authorized representative" means: | 18 | | (1) a person to whom a covered person has given express | 19 | | written consent to represent the covered person for | 20 | | purposes of this Law; | 21 | | (2) a person authorized by law to provide substituted | 22 | | consent for a covered person; | 23 | | (3) a family member of the covered person or the | 24 | | covered person's treating health care professional when | 25 | | the covered person is unable to provide consent; | 26 | | (4) a health care provider when the covered person's |
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| 1 | | health benefit plan requires that a request for a benefit | 2 | | under the plan be initiated by the health care provider; or | 3 | | (5) in the case of an urgent care request, a health | 4 | | care provider with knowledge of the covered person's | 5 | | medical condition. | 6 | | (1) a person to whom a covered person has given express | 7 | | written consent to represent the covered person in an | 8 | | external review, including the covered person's health | 9 | | care provider; | 10 | | (2) a person authorized by law to provide substituted | 11 | | consent for a covered person; or | 12 | | (3) the covered person's health care provider when the | 13 | | covered person is unable to provide consent. | 14 | | "Best evidence" means evidence based on: | 15 | | (1) randomized clinical trials; | 16 | | (2) if randomized clinical trials are not available, | 17 | | then cohort studies or case-control studies; | 18 | | (3) if items (1) and (2) are not available, then | 19 | | case-series; or | 20 | | (4) if items (1), (2), and (3) are not available, then | 21 | | expert opinion. | 22 | | "Case-series" means an evaluation of a series of patients | 23 | | with a particular outcome, without the use of a control group. | 24 | | "Clinical review criteria" means the written screening | 25 | | procedures, decision abstracts, clinical protocols, and | 26 | | practice guidelines used by a health carrier to determine the |
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| 1 | | necessity and appropriateness of health care services. | 2 | | "Cohort study" means a prospective evaluation of 2 groups | 3 | | of patients with only one group of patients receiving specific | 4 | | intervention. | 5 | | "Concurrent review" means a review conducted during a | 6 | | patient's stay or course of treatment in a facility, the office | 7 | | of a health care professional, or other inpatient or outpatient | 8 | | health care setting. | 9 | | "Covered benefits" or "benefits" means those health care | 10 | | services to which a covered person is entitled under the terms | 11 | | of a health benefit plan. | 12 | | "Covered person" means a policyholder, subscriber, | 13 | | enrollee, or other individual participating in a health benefit | 14 | | plan. | 15 | | "Director" means the Director of the Department of | 16 | | Insurance. | 17 | | "Emergency medical condition" means a medical condition | 18 | | manifesting itself by acute symptoms of sufficient severity, | 19 | | including, but not limited to, severe pain, 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 | 25 | | unborn child, in serious jeopardy; | 26 | | (2) serious impairment to bodily functions; or
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| 1 | | (3) serious dysfunction of any bodily organ or part. | 2 | | "Emergency services" means health care items and services | 3 | | furnished or required to evaluate and treat an emergency | 4 | | medical condition. | 5 | | "Evidence-based standard" means the conscientious, | 6 | | explicit, and judicious use of the current best evidence based | 7 | | on an overall systematic review of the research in making | 8 | | decisions about the care of individual patients. | 9 | | "Expert opinion" means a belief or an interpretation by | 10 | | specialists with experience in a specific area about the | 11 | | scientific evidence pertaining to a particular service, | 12 | | intervention, or therapy. | 13 | | "Facility" means an institution providing health care | 14 | | services or a health care setting. | 15 | | "Final adverse determination" means an adverse | 16 | | determination involving a covered benefit that has been upheld | 17 | | by a health carrier, or its designee utilization review | 18 | | organization, at the completion of the health carrier's | 19 | | internal grievance process procedures as set forth by the | 20 | | Managed Care Reform and Patient Rights Act. | 21 | | "Health benefit plan" means a policy, contract, | 22 | | certificate, plan, or agreement offered or issued by a health | 23 | | carrier to provide, deliver, arrange for, pay for, or reimburse | 24 | | any of the costs of health care services. | 25 | | "Health care provider" or "provider" means a physician, | 26 | | hospital facility, or other health care practitioner licensed, |
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| 1 | | accredited, or certified to perform specified health care | 2 | | services consistent with State law, responsible for | 3 | | recommending health care services on behalf of a covered | 4 | | person. | 5 | | "Health care services" means services for the diagnosis, | 6 | | prevention, treatment, cure, or relief of a health condition, | 7 | | illness, injury, or disease. | 8 | | "Health carrier" means an entity subject to the insurance | 9 | | laws and regulations of this State, or subject to the | 10 | | jurisdiction of the Director, that contracts or offers to | 11 | | contract to provide, deliver, arrange for, pay for, or | 12 | | reimburse any of the costs of health care services, including a | 13 | | sickness and accident insurance company, a health maintenance | 14 | | organization, or any other entity providing a plan of health | 15 | | insurance, health benefits, or health care services. "Health | 16 | | carrier" also means Limited Health Service Organizations | 17 | | (LHSO) and Voluntary Health Service Plans. | 18 | | "Health information" means information or data, whether | 19 | | oral or recorded in any form or medium, and personal facts or | 20 | | information about events or relationships that relate to:
| 21 | | (1) the past, present, or future physical, mental, or | 22 | | behavioral health or condition of an individual or a member | 23 | | of the individual's family; | 24 | | (2) the provision of health care services to an | 25 | | individual; or | 26 | | (3) payment for the provision of health care services |
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| 1 | | to an individual. | 2 | | "Independent review organization" means an entity that | 3 | | conducts independent external reviews of adverse | 4 | | determinations and final adverse determinations. | 5 | | "Medical or scientific evidence" means evidence found in | 6 | | the following sources: | 7 | | (1) peer-reviewed scientific studies published in or | 8 | | accepted for publication by medical journals that meet | 9 | | nationally recognized requirements for scientific | 10 | | manuscripts and that submit most of their published | 11 | | articles for review by experts who are not part of the | 12 | | editorial staff; | 13 | | (2) peer-reviewed medical literature, including | 14 | | literature relating to therapies reviewed and approved by a | 15 | | qualified institutional review board, biomedical | 16 | | compendia, and other medical literature that meet the | 17 | | criteria of the National Institutes of Health's Library of | 18 | | Medicine for indexing in Index Medicus (Medline) and | 19 | | Elsevier Science Ltd. for indexing in Excerpta Medicus | 20 | | (EMBASE); | 21 | | (3) medical journals recognized by the Secretary of | 22 | | Health and Human Services under Section 1861(t)(2) of the | 23 | | federal Social Security Act; | 24 | | (4) the following standard reference compendia:
| 25 | | (a) The American Hospital Formulary Service-Drug | 26 | | Information; |
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| 1 | | (b) Drug Facts and Comparisons; | 2 | | (c) The American Dental Association Accepted | 3 | | Dental Therapeutics; and | 4 | | (d) The United States Pharmacopoeia-Drug | 5 | | Information; | 6 | | (5) findings, studies, or research conducted by or | 7 | | under the auspices of federal government agencies and | 8 | | nationally recognized federal research institutes, | 9 | | including: | 10 | | (a) the federal Agency for Healthcare Research and | 11 | | Quality; | 12 | | (b) the National Institutes of Health; | 13 | | (c) the National Cancer Institute; | 14 | | (d) the National Academy of Sciences; | 15 | | (e) the Centers for Medicare & Medicaid Services; | 16 | | (f) the federal Food and Drug Administration; and | 17 | | (g) any national board recognized by the National | 18 | | Institutes of Health for the purpose of evaluating the | 19 | | medical value of health care services; or | 20 | | (6) any other medical or scientific evidence that is | 21 | | comparable to the sources listed in items (1) through (5). | 22 | | "Person" means an individual, a corporation, a | 23 | | partnership, an association, a joint venture, a joint stock | 24 | | company, a trust, an unincorporated organization, any similar | 25 | | entity, or any combination of the foregoing. | 26 | | "Prospective review" means a review conducted prior to an |
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| 1 | | admission or the provision of a health care service or a course | 2 | | of treatment in accordance with a health carrier's requirement | 3 | | that the health care service or course of treatment, in whole | 4 | | or in part, be approved prior to its provision. | 5 | | "Protected health information" means health information | 6 | | (i) that identifies an individual who is the subject of the | 7 | | information; or (ii) with respect to which there is a | 8 | | reasonable basis to believe that the information could be used | 9 | | to identify an individual. | 10 | | "Randomized clinical trial" means a controlled prospective | 11 | | study of patients that have been randomized into an | 12 | | experimental group and a control group at the beginning of the | 13 | | study with only the experimental group of patients receiving a | 14 | | specific intervention, which includes study of the groups for | 15 | | variables and anticipated outcomes over time. | 16 | | "Retrospective review" means any review of a request for a | 17 | | benefit that is not a concurrent or prospective review request. | 18 | | "Retrospective review" does not include the review of a claim | 19 | | that is limited to veracity of documentation or accuracy of | 20 | | coding. means a review of medical necessity conducted after | 21 | | services have been provided to a patient, but does not include | 22 | | the review of a claim that is limited to an evaluation of | 23 | | reimbursement levels, veracity of documentation, accuracy of | 24 | | coding, or adjudication for payment . | 25 | | "Utilization review" has the meaning provided by the | 26 | | Managed Care Reform and Patient Rights Act. |
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| 1 | | "Utilization review organization" means a utilization | 2 | | review program as defined in the Managed Care Reform and | 3 | | Patient Rights Act.
| 4 | | (Source: P.A. 96-857, eff. 7-1-10 .) | 5 | | (215 ILCS 180/20)
| 6 | | Sec. 20. Notice of right to external review. | 7 | | (a) At the same time the health carrier sends written | 8 | | notice of a covered person's right to appeal a coverage | 9 | | decision upon an adverse determination or a final adverse | 10 | | determination as provided by the Managed Care Reform and | 11 | | Patient Rights Act , a health carrier shall notify a covered | 12 | | person , the covered person's authorized representative, if | 13 | | any, and a covered person's health care provider in writing of | 14 | | the covered person's right to request an external review as | 15 | | provided by this Act. The written notice required shall include | 16 | | the following, or substantially equivalent, language: "We have | 17 | | denied your request for the provision of or payment for a | 18 | | health care service or course of treatment. You have the right | 19 | | to have our decision reviewed by an independent review | 20 | | organization not associated with us if our decision involved | 21 | | making a judgment as to the medical necessity, appropriateness, | 22 | | health care setting, level of care, or effectiveness of the | 23 | | health care service or treatment you requested by submitting a | 24 | | written request for an external review to the Department of | 25 | | Insurance, Office of Consumer Health Information, 320 West |
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| 1 | | Washington Street, 4th Floor, Springfield, Illinois, 62767." | 2 | | us . Upon receipt of your request an independent review | 3 | | organization registered with the Department of Insurance will | 4 | | be assigned to review our decision. | 5 | | (a-5) The Department may prescribe the form and content of | 6 | | the notice required under this Section. | 7 | | (b) This subsection (b) shall apply to an expedited review | 8 | | prior to a final adverse determination. In addition to the | 9 | | notice required in subsection (a), for the health carrier shall | 10 | | include a notice related to an adverse determination, the | 11 | | health carrier shall include a statement informing the covered | 12 | | person of all of the following: | 13 | | (1) If the covered person has a medical condition where | 14 | | the timeframe for completion of (A) an expedited internal | 15 | | review of an appeal a grievance involving an adverse | 16 | | determination, (B) a final adverse determination as set | 17 | | forth in the Managed Care Reform and Patient Rights Act , or | 18 | | (C) a standard external review as established in this Act, | 19 | | would seriously jeopardize the life or health of the | 20 | | covered person or would jeopardize the covered person's | 21 | | ability to regain maximum function, then the covered person | 22 | | or the covered person's authorized representative may file | 23 | | a request for an expedited external review. | 24 | | (2) The covered person or the covered person's | 25 | | authorized representative may file an appeal under the | 26 | | health carrier's internal appeal process, but if the health |
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| 1 | | carrier has not issued a written decision to the covered | 2 | | person or the covered person's authorized representative | 3 | | 30 days following the date the covered person or the | 4 | | covered person's authorized representative files an appeal | 5 | | of an adverse determination that involves a concurrent or | 6 | | prospective review request or 60 days following the date | 7 | | the covered person or the covered person's authorized | 8 | | representative files an appeal of an adverse determination | 9 | | that involves a retrospective review request with the | 10 | | health carrier and the covered person or the covered | 11 | | person's authorized representative has not requested or | 12 | | agreed to a delay, then the covered person or the covered | 13 | | person's authorized representative may file a request for | 14 | | external review and shall be considered to have exhausted | 15 | | the health carrier's internal appeal process for purposes | 16 | | of this Act. The covered person or the covered person's | 17 | | authorized representative may file a request for an | 18 | | expedited external review at the same time the covered | 19 | | person or the covered person's authorized representative | 20 | | files a request for an expedited internal appeal involving | 21 | | an adverse determination as set forth in the Managed Care | 22 | | Reform and Patient Rights Act if the adverse determination | 23 | | involves a denial of coverage based on a determination that | 24 | | the recommended or requested health care service or | 25 | | treatment is experimental or investigational and the | 26 | | covered person's health care provider certifies in writing |
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| 1 | | that the recommended or requested health care service or | 2 | | treatment that is the subject of the adverse determination | 3 | | would be significantly less effective if not promptly | 4 | | initiated. The independent review organization assigned to | 5 | | conduct the expedited external review will determine | 6 | | whether the covered person shall be required to complete | 7 | | the expedited review of the grievance prior to conducting | 8 | | the expedited external review. | 9 | | (3) If the covered person or the covered person's | 10 | | authorized representative filed a request for an expedited | 11 | | internal review of an adverse determination and has not | 12 | | received a decision on such request from the health carrier | 13 | | within 48 hours, except to the extent the covered person or | 14 | | the covered person's authorized representative requested | 15 | | or agreed to a delay, then the covered person or the | 16 | | covered person's authorized representative may file a | 17 | | request for external review and shall be considered to have | 18 | | exhausted the health carrier's internal appeal process for | 19 | | the purposes of this Act. | 20 | | (4) (3) If an adverse determination concerns a denial | 21 | | of coverage based on a determination that the recommended | 22 | | or requested health care service or treatment is | 23 | | experimental or investigational and the covered person's | 24 | | health care provider certifies in writing that the | 25 | | recommended or requested health care service or treatment | 26 | | that is the subject of the request would be significantly |
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| 1 | | less effective if not promptly initiated, then the covered | 2 | | person or the covered person's authorized representative | 3 | | may request an expedited external review at the same time | 4 | | the covered person or the covered person's authorized | 5 | | representative files a request for an expedited internal | 6 | | appeal involving an adverse determination. The independent | 7 | | review organization assigned to conduct the expedited | 8 | | external review shall determine whether the covered person | 9 | | is required to complete the expedited review of the appeal | 10 | | prior to conducting the expedited external review . | 11 | | (c) This subsection (c) shall apply to an expedited review | 12 | | upon final adverse determination. In addition to the notice | 13 | | required in subsection (a), for the health carrier shall | 14 | | include a notice related to a final adverse determination, the | 15 | | health carrier shall include a statement informing the covered | 16 | | person of all of the following: | 17 | | (1) if the covered person has a medical condition where | 18 | | the timeframe for completion of a standard external review | 19 | | would seriously jeopardize the life or health of the | 20 | | covered person or would jeopardize the covered person's | 21 | | ability to regain maximum function, then the covered person | 22 | | or the covered person's authorized representative may file | 23 | | a request for an expedited external review; or | 24 | | (2) if a final adverse determination concerns an | 25 | | admission, availability of care, continued stay, or health | 26 | | care service for which the covered person received |
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| 1 | | emergency services, but has not been discharged from a | 2 | | facility, then the covered person, or the covered person's | 3 | | authorized representative, may request an expedited | 4 | | external review; or | 5 | | (3) if a final adverse determination concerns a denial | 6 | | of coverage based on a determination that the recommended | 7 | | or requested health care service or treatment is | 8 | | experimental or investigational, and the covered person's | 9 | | health care provider certifies in writing that the | 10 | | recommended or requested health care service or treatment | 11 | | that is the subject of the request would be significantly | 12 | | less effective if not promptly initiated, then the covered | 13 | | person or the covered person's authorized representative | 14 | | may request an expedited external review. | 15 | | (d) In addition to the information to be provided pursuant | 16 | | to subsections (a), (b), and (c) of this Section, the health | 17 | | carrier shall include a copy of the description of both the | 18 | | required standard and expedited external review procedures. | 19 | | The description shall highlight the external review procedures | 20 | | that give the covered person or the covered person's authorized | 21 | | representative the opportunity to submit additional | 22 | | information, including any forms used to process an external | 23 | | review.
| 24 | | (e) As part of any forms provided under subsection (d) of | 25 | | this Section, the health carrier shall include an authorization | 26 | | form, or other document approved by the Director, by which the |
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| 1 | | covered person, for purposes of conducting an external review | 2 | | under this Act, authorizes the health carrier and the covered | 3 | | person's treating health care provider to disclose protected | 4 | | health information, including medical records, concerning the | 5 | | covered person that is pertinent to the external review, as | 6 | | provided in the Illinois Insurance Code. | 7 | | (Source: P.A. 96-857, eff. 7-1-10 .) | 8 | | (215 ILCS 180/25)
| 9 | | Sec. 25. Request for external review. A covered person or | 10 | | the covered person's authorized representative may make a | 11 | | request for a standard external or expedited external review of | 12 | | an adverse determination or final adverse determination. | 13 | | Except as set forth in Sections 40 and 42 of this Act, all | 14 | | requests for external review Requests under this Section shall | 15 | | be made in writing to the Director directly to the health | 16 | | carrier that made the adverse or final adverse determination. | 17 | | All requests for external review shall be in writing except for | 18 | | requests for expedited external reviews which may me made | 19 | | orally . Health carriers must provide covered persons with forms | 20 | | to request external reviews.
| 21 | | (Source: P.A. 96-857, eff. 7-1-10 .) | 22 | | (215 ILCS 180/30)
| 23 | | Sec. 30. Exhaustion of internal appeal grievance process. | 24 | | (a) Except as provided in subsection (b) of this Section |
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| 1 | | 20 , a request for an external review shall not be made until | 2 | | the covered person has exhausted the health carrier's internal | 3 | | appeal grievance process as set forth in the Managed Care | 4 | | Reform and Patient Rights Act . | 5 | | (b) A covered person shall also be considered to have | 6 | | exhausted the health carrier's internal appeal grievance | 7 | | process for purposes of this Section if: | 8 | | (1) the covered person or the covered person's | 9 | | authorized representative has filed an appeal under the | 10 | | health carrier's internal appeal process a request for an | 11 | | internal review of an adverse determination pursuant to the | 12 | | Managed Care Reform and Patient Rights Act and has not | 13 | | received a written decision on the appeal 30 days following | 14 | | the date the covered person or the covered person's | 15 | | authorized representative files an appeal of an adverse | 16 | | determination that involves a concurrent or prospective | 17 | | review request or 60 days following the date the covered | 18 | | person or the covered person's authorized representative | 19 | | files an appeal of an adverse determination that involves a | 20 | | retrospective review request request from the health | 21 | | carrier within 15 days after receipt of the required | 22 | | information but not more than 30 days after the request was | 23 | | filed by the covered person or the covered person's | 24 | | authorized representative , except to the extent the | 25 | | covered person or the covered person's authorized | 26 | | representative requested or agreed to a delay; however, a |
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| 1 | | covered person or the covered person's authorized | 2 | | representative may not make a request for an external | 3 | | review of an adverse determination involving a | 4 | | retrospective review determination until the covered | 5 | | person has exhausted the health carrier's internal | 6 | | grievance process; | 7 | | (2) the covered person or the covered person's | 8 | | authorized representative filed a request for an expedited | 9 | | internal review of an adverse determination pursuant to the | 10 | | Managed Care Reform and Patient Rights Act and has not | 11 | | received a decision on such request from the health carrier | 12 | | within 48 hours, except to the extent the covered person or | 13 | | the covered person's authorized representative requested | 14 | | or agreed to a delay; or | 15 | | (3) the health carrier agrees to waive the exhaustion | 16 | | requirement ; .
| 17 | | (4) the covered person has a medical condition in which | 18 | | the timeframe for completion of (A) an expedited internal | 19 | | review of an appeal involving an adverse determination, (B) | 20 | | a final adverse determination, or (C) a standard external | 21 | | review as established in this Act would seriously | 22 | | jeopardize the life or health of the covered person or | 23 | | would jeopardize the covered person's ability to regain | 24 | | maximum function; | 25 | | (5) an adverse determination concerns a denial of | 26 | | coverage based on a determination that the recommended or |
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| 1 | | requested health care service or treatment is experimental | 2 | | or investigational and the covered person's health care | 3 | | provider certifies in writing that the recommended or | 4 | | requested health care service or treatment that is the | 5 | | subject of the request would be significantly less | 6 | | effective if not promptly initiated; in such cases, the | 7 | | covered person or the covered person's authorized | 8 | | representative may request an expedited external review at | 9 | | the same time the covered person or the covered person's | 10 | | authorized representative files a request for an expedited | 11 | | internal appeal involving an adverse determination; the | 12 | | independent review organization assigned to conduct the | 13 | | expedited external review shall determine whether the | 14 | | covered person is required to complete the expedited review | 15 | | of the appeal prior to conducting the expedited external | 16 | | review; or | 17 | | (6) the health carrier has failed to comply with | 18 | | applicable State and federal law governing internal claims | 19 | | and appeals procedures. | 20 | | (Source: P.A. 96-857, eff. 7-1-10 .) | 21 | | (215 ILCS 180/35)
| 22 | | Sec. 35. Standard external review. | 23 | | (a) Within 4 months after the date of receipt of a notice | 24 | | of an adverse determination or final adverse determination, a | 25 | | covered person or the covered person's authorized |
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| 1 | | representative may file a request for an external review with | 2 | | the Director. Within one business day after the date of receipt | 3 | | of a request for external review, the Director shall send a | 4 | | copy of the request to the health carrier. | 5 | | (b) Within 5 business days following the date of receipt of | 6 | | the external review request, the health carrier shall complete | 7 | | a preliminary review of the request to determine whether:
| 8 | | (1) the individual is or was a covered person in the | 9 | | health benefit plan at the time the health care service was | 10 | | requested or at the time the health care service was | 11 | | provided; | 12 | | (2) the health care service that is the subject of the | 13 | | adverse determination or the final adverse determination | 14 | | is a covered service under the covered person's health | 15 | | benefit plan, but the health carrier has determined that | 16 | | the health care service is not covered because it does not | 17 | | meet the health carrier's requirements for medical | 18 | | necessity, appropriateness, health care setting, level of | 19 | | care, or effectiveness ; | 20 | | (3) the covered person has exhausted the health | 21 | | carrier's internal appeal grievance process unless the | 22 | | covered person is not required to exhaust the health | 23 | | carrier's internal appeal process pursuant to as set forth | 24 | | in this Act; | 25 | | (4) (blank); and for appeals relating to a | 26 | | determination based on treatment being experimental or |
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| 1 | | investigational, the requested health care service or | 2 | | treatment that is the subject of the adverse determination | 3 | | or final adverse determination is a covered benefit under | 4 | | the covered person's health benefit plan except for the | 5 | | health carrier's determination that the service or | 6 | | treatment is experimental or investigational for a | 7 | | particular medical condition and is not explicitly listed | 8 | | as an excluded benefit under the covered person's health | 9 | | benefit plan with the health carrier and that the covered | 10 | | person's health care provider, who ordered or provided the | 11 | | services in question and who is licensed under the
Medical | 12 | | Practice Act of 1987, has certified that one of the | 13 | | following situations is applicable: | 14 | | (A) standard health care services or treatments | 15 | | have not been effective in improving the condition of | 16 | | the covered person; | 17 | | (B) standard health care services or treatments | 18 | | are not medically appropriate for the covered person; | 19 | | (C) there is no available standard health care | 20 | | service or treatment covered by the health carrier that | 21 | | is more beneficial than the recommended or requested | 22 | | health care service or treatment;
| 23 | | (D) the health care service or treatment is likely | 24 | | to be more beneficial to the covered person, in the | 25 | | health care provider's opinion, than any available | 26 | | standard health care services or treatments; or |
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| 1 | | (E) that scientifically valid studies using | 2 | | accepted protocols demonstrate that the health care | 3 | | service or treatment requested is likely to be more | 4 | | beneficial to the covered person than any available | 5 | | standard health care services or treatments; and | 6 | | (5) the covered person has provided all the information | 7 | | and forms required to process an external review, as | 8 | | specified in this Act. | 9 | | (c) Within one business day after completion of the | 10 | | preliminary review, the health carrier shall notify the | 11 | | Director and covered person and, if applicable, the covered | 12 | | person's authorized representative in writing whether the | 13 | | request is complete and eligible for external review. If the | 14 | | request: | 15 | | (1) is not complete, the health carrier shall inform | 16 | | the Director and covered person and, if applicable, the | 17 | | covered person's authorized representative in writing and | 18 | | include in the notice what information or materials are | 19 | | required by this Act to make the request complete; or | 20 | | (2) is not eligible for external review, the health | 21 | | carrier shall inform the Director and covered person and, | 22 | | if applicable, the covered person's authorized | 23 | | representative in writing and include in the notice the | 24 | | reasons for its ineligibility.
| 25 | | The Department may specify the form for the health | 26 | | carrier's notice of initial determination under this |
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| 1 | | subsection (c) and any supporting information to be included in | 2 | | the notice. | 3 | | The notice of initial determination of ineligibility shall | 4 | | include a statement informing the covered person and, if | 5 | | applicable, the covered person's authorized representative | 6 | | that a health carrier's initial determination that the external | 7 | | review request is ineligible for review may be appealed to the | 8 | | Director by filing a complaint with the Director. | 9 | | Notwithstanding a health carrier's initial determination | 10 | | that the request is ineligible for external review, the | 11 | | Director may determine that a request is eligible for external | 12 | | review and require that it be referred for external review. In | 13 | | making such determination, the Director's decision shall be in | 14 | | accordance with the terms of the covered person's health | 15 | | benefit plan , unless such terms are inconsistent with | 16 | | applicable law, and shall be subject to all applicable | 17 | | provisions of this Act. | 18 | | (d) Whenever the Director receives notice that a request is | 19 | | eligible for external review following the preliminary review | 20 | | conducted pursuant to this Section the health carrier shall , | 21 | | within one 5 business day after the date of receipt of the | 22 | | notice, the Director shall days : | 23 | | (1) assign an independent review organization from the | 24 | | list of approved independent review organizations compiled | 25 | | and maintained by the Director pursuant to this Act and | 26 | | notify the health carrier of the name of the assigned |
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| 1 | | independent review organization ; and | 2 | | (2) notify in writing the covered person and, if | 3 | | applicable, the covered person's authorized representative | 4 | | of the request's eligibility and acceptance for external | 5 | | review and the name of the independent review organization. | 6 | | The Director health carrier shall include in the notice | 7 | | provided to the covered person and, if applicable, the covered | 8 | | person's authorized representative a statement that the | 9 | | covered person or the covered person's authorized | 10 | | representative may, within 5 business days following the date | 11 | | of receipt of the notice provided pursuant to item (2) of this | 12 | | subsection (d), submit in writing to the assigned independent | 13 | | review organization additional information that the | 14 | | independent review organization shall consider when conducting | 15 | | the external review. The independent review organization is not | 16 | | required to, but may, accept and consider additional | 17 | | information submitted after 5 business days. | 18 | | (e) The assignment by the Director of an approved | 19 | | independent review organization to conduct an external review | 20 | | in accordance with this Section shall be done on a random basis | 21 | | among those independent review organizations approved by the | 22 | | Director pursuant to this Act. The assignment of an approved | 23 | | independent review organization to conduct an external review | 24 | | in accordance with this Section shall be made from those | 25 | | approved independent review organizations qualified to conduct | 26 | | external review as required by Sections 50 and 55 of this Act. |
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| 1 | | (f) Within Upon assignment of an independent review | 2 | | organization, the health carrier or its designee utilization | 3 | | review organization shall, within 5 business days after the | 4 | | date of receipt of the notice provided pursuant to item (1) of | 5 | | subsection (d) of this Section , the health carrier or its | 6 | | designee utilization review organization shall provide to the | 7 | | assigned independent review organization the documents and any | 8 | | information considered in making the adverse determination or | 9 | | final adverse determination; in such cases, the following | 10 | | provisions shall apply: | 11 | | (1) Except as provided in item (2) of this subsection | 12 | | (f), failure by the health carrier or its utilization | 13 | | review organization to provide the documents and | 14 | | information within the specified time frame shall not delay | 15 | | the conduct of the external review. | 16 | | (2) If the health carrier or its utilization review | 17 | | organization fails to provide the documents and | 18 | | information within the specified time frame, the assigned | 19 | | independent review organization may terminate the external | 20 | | review and make a decision to reverse the adverse | 21 | | determination or final adverse determination. | 22 | | (3) Within one business day after making the decision | 23 | | to terminate the external review and make a decision to | 24 | | reverse the adverse determination or final adverse | 25 | | determination under item (2) of this subsection (f), the | 26 | | independent review organization shall notify the Director, |
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| 1 | | the health carrier, the covered person and, if applicable, | 2 | | the covered person's authorized representative, of its | 3 | | decision to reverse the adverse determination. | 4 | | (g) Upon receipt of the information from the health carrier | 5 | | or its utilization review organization, the assigned | 6 | | independent review organization shall review all of the | 7 | | information and documents and any other information submitted | 8 | | in writing to the independent review organization by the | 9 | | covered person and the covered person's authorized | 10 | | representative. | 11 | | (h) Upon receipt of any information submitted by the | 12 | | covered person or the covered person's authorized | 13 | | representative, the independent review organization shall | 14 | | forward the information to the health carrier within 1 business | 15 | | day. | 16 | | (1) Upon receipt of the information, if any, the health | 17 | | carrier may reconsider its adverse determination or final | 18 | | adverse determination that is the subject of the external | 19 | | review.
| 20 | | (2) Reconsideration by the health carrier of its | 21 | | adverse determination or final adverse determination shall | 22 | | not delay or terminate the external review.
| 23 | | (3) The external review may only be terminated if the | 24 | | health carrier decides, upon completion of its | 25 | | reconsideration, to reverse its adverse determination or | 26 | | final adverse determination and provide coverage or |
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| 1 | | payment for the health care service that is the subject of | 2 | | the adverse determination or final adverse determination. | 3 | | In such cases, the following provisions shall apply: | 4 | | (A) Within one business day after making the | 5 | | decision to reverse its adverse determination or final | 6 | | adverse determination, the health carrier shall notify | 7 | | the Director, the covered person and , if applicable, | 8 | | the covered person's authorized representative, and | 9 | | the assigned independent review organization in | 10 | | writing of its decision. | 11 | | (B) Upon notice from the health carrier that the | 12 | | health carrier has made a decision to reverse its | 13 | | adverse determination or final adverse determination, | 14 | | the assigned independent review organization shall | 15 | | terminate the external review. | 16 | | (i) In addition to the documents and information provided | 17 | | by the health carrier or its utilization review organization | 18 | | and the covered person and the covered person's authorized | 19 | | representative, if any, the independent review organization, | 20 | | to the extent the information or documents are available and | 21 | | the independent review organization considers them | 22 | | appropriate, shall consider the following in reaching a | 23 | | decision: | 24 | | (1) the covered person's pertinent medical records; | 25 | | (2) the covered person's health care provider's | 26 | | recommendation; |
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| 1 | | (3) consulting reports from appropriate health care | 2 | | providers and other documents submitted by the health | 3 | | carrier or its designee utilization review organization , | 4 | | the covered person, the covered person's authorized | 5 | | representative, or the covered person's treating provider; | 6 | | (4) the terms of coverage under the covered person's | 7 | | health benefit plan with the health carrier to ensure that | 8 | | the independent review organization's decision is not | 9 | | contrary to the terms of coverage under the covered | 10 | | person's health benefit plan with the health carrier , | 11 | | unless the terms are inconsistent with applicable law ; | 12 | | (5) the most appropriate practice guidelines, which | 13 | | shall include applicable evidence-based standards and may | 14 | | include any other practice guidelines developed by the | 15 | | federal government, national or professional medical | 16 | | societies, boards, and associations; | 17 | | (6) any applicable clinical review criteria developed | 18 | | and used by the health carrier or its designee utilization | 19 | | review organization; and | 20 | | (7) the opinion of the independent review | 21 | | organization's clinical reviewer or reviewers after | 22 | | considering items (1) through (6) of this subsection (i) to | 23 | | the extent the information or documents are available and | 24 | | the clinical reviewer or reviewers considers the | 25 | | information or documents appropriate; and | 26 | | (8) (blank). for a denial of coverage based on a |
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| 1 | | determination that the health care service or treatment | 2 | | recommended or requested is experimental or | 3 | | investigational, whether and to what extent: | 4 | | (A) the recommended or requested health care | 5 | | service or treatment has been approved by the federal | 6 | | Food and Drug Administration, if applicable, for the | 7 | | condition; | 8 | | (B) medical or scientific evidence or | 9 | | evidence-based standards demonstrate that the expected | 10 | | benefits of the recommended or requested health care | 11 | | service or treatment is more likely than not to be | 12 | | beneficial to the covered person than any available | 13 | | standard health care service or treatment and the | 14 | | adverse risks of the recommended or requested health | 15 | | care service or treatment would not be substantially | 16 | | increased over those of available standard health care | 17 | | services or treatments; or | 18 | | (C) the terms of coverage under the covered | 19 | | person's health benefit plan with the health carrier to | 20 | | ensure that the health care service or treatment that | 21 | | is the subject of the opinion is experimental or | 22 | | investigational would otherwise be covered under the | 23 | | terms of coverage of the covered person's health | 24 | | benefit plan with the health carrier. | 25 | | (j) Within 5 days after the date of receipt of all | 26 | | necessary information, but in no event more than 45 days after |
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| 1 | | the date of receipt of the request for an external review, the | 2 | | assigned independent review organization shall provide written | 3 | | notice of its decision to uphold or reverse the adverse | 4 | | determination or the final adverse determination to the | 5 | | Director, the health carrier, the covered person , and, if | 6 | | applicable, the covered person's authorized representative. In | 7 | | reaching a decision, the assigned independent review | 8 | | organization is not bound by any claim determinations reached | 9 | | prior to the submission of information to the independent | 10 | | review organization. In such cases, the following provisions | 11 | | shall apply: | 12 | | (1) The independent review organization shall include | 13 | | in the notice: | 14 | | (A) a general description of the reason for the | 15 | | request for external review; | 16 | | (B) the date the independent review organization | 17 | | received the assignment from the Director health | 18 | | carrier to conduct the external review; | 19 | | (C) the time period during which the external | 20 | | review was conducted; | 21 | | (D) references to the evidence or documentation, | 22 | | including the evidence-based standards, considered in | 23 | | reaching its decision; | 24 | | (E) the date of its decision; and | 25 | | (F) the principal reason or reasons for its | 26 | | decision, including what applicable, if any, |
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| 1 | | evidence-based standards that were a basis for its | 2 | | decision ; and .
| 3 | | (G) the rationale for its decision. | 4 | | (2) (Blank). For reviews of experimental or | 5 | | investigational treatments, the notice shall include the | 6 | | following information: | 7 | | (A) a description of the covered person's medical | 8 | | condition; | 9 | | (B) a description of the indicators relevant to | 10 | | whether there is sufficient evidence to demonstrate | 11 | | that the recommended or requested health care service | 12 | | or treatment is more likely than not to be more | 13 | | beneficial to the covered person than any available | 14 | | standard health care services or treatments and the | 15 | | adverse risks of the recommended or requested health | 16 | | care service or treatment would not be substantially | 17 | | increased over those of available standard health care | 18 | | services or treatments; | 19 | | (C) a description and analysis of any medical or | 20 | | scientific evidence considered in reaching the | 21 | | opinion; | 22 | | (D) a description and analysis of any | 23 | | evidence-based standards; | 24 | | (E) whether the recommended or requested health | 25 | | care service or treatment has been approved by the | 26 | | federal Food and Drug Administration, for the |
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| 1 | | condition; | 2 | | (F) whether medical or scientific evidence or | 3 | | evidence-based standards demonstrate that the expected | 4 | | benefits of the recommended or requested health care | 5 | | service or treatment is more likely than not to be more | 6 | | beneficial to the covered person than any available | 7 | | standard health care service or treatment and the | 8 | | adverse risks of the recommended or requested health | 9 | | care service or treatment would not be substantially | 10 | | increased over those of available standard health care | 11 | | services or treatments; and | 12 | | (G) the written opinion of the clinical reviewer, | 13 | | including the reviewer's recommendation as to whether | 14 | | the recommended or requested health care service or | 15 | | treatment should be covered and the rationale for the | 16 | | reviewer's recommendation. | 17 | | (3) (Blank). In reaching a decision, the assigned | 18 | | independent review organization is not bound by any | 19 | | decisions or conclusions reached during the health | 20 | | carrier's utilization review process or the health | 21 | | carrier's internal grievance or appeals process. | 22 | | (4) Upon receipt of a notice of a decision reversing | 23 | | the adverse determination or final adverse determination, | 24 | | the health carrier immediately shall approve the coverage | 25 | | that was the subject of the adverse determination or final | 26 | | adverse determination.
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| 1 | | (Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.) | 2 | | (215 ILCS 180/40)
| 3 | | Sec. 40. Expedited external review. | 4 | | (a) A covered person or a covered person's authorized | 5 | | representative may file a request for an expedited external | 6 | | review with the Director health carrier either orally or in | 7 | | writing: | 8 | | (1) immediately after the date of receipt of a notice | 9 | | prior to a final adverse determination as provided by | 10 | | subsection (b) of Section 20 of this Act; | 11 | | (2) immediately after the date of receipt of a notice | 12 | | upon a final adverse determination as provided by | 13 | | subsection (c) of Section 20 of this Act; or | 14 | | (3) if a health carrier fails to provide a decision on | 15 | | request for an expedited internal appeal within 48 hours as | 16 | | provided by item (2) of Section 30 of this Act. | 17 | | (b) Upon receipt of a request for an expedited external | 18 | | review, the Director shall immediately send a copy of the | 19 | | request to the health carrier. Immediately upon receipt of the | 20 | | request for an expedited external review as provided under | 21 | | subsections (b) and (c) of Section 20 , the health carrier shall | 22 | | determine whether the request meets the reviewability | 23 | | requirements set forth in items (1), (2), and (4) of subsection | 24 | | (b) of Section 35. In such cases, the following provisions | 25 | | shall apply: |
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| 1 | | (1) The health carrier shall immediately notify the | 2 | | Director, the covered person , and, if applicable, the | 3 | | covered person's authorized representative of its | 4 | | eligibility determination. | 5 | | (2) The notice of initial determination shall include a | 6 | | statement informing the covered person and, if applicable, | 7 | | the covered person's authorized representative that a | 8 | | health carrier's initial determination that an external | 9 | | review request is ineligible for review may be appealed to | 10 | | the Director. | 11 | | (3) The Director may determine that a request is | 12 | | eligible for expedited external review notwithstanding a | 13 | | health carrier's initial determination that the request is | 14 | | ineligible and require that it be referred for external | 15 | | review. | 16 | | (4) In making a determination under item (3) of this | 17 | | subsection (b), the Director's decision shall be made in | 18 | | accordance with the terms of the covered person's health | 19 | | benefit plan , unless such terms are inconsistent with | 20 | | applicable law, and shall be subject to all applicable | 21 | | provisions of this Act. | 22 | | (5) The Director may specify the form for the health | 23 | | carrier's notice of initial determination under this | 24 | | subsection (b) and any supporting information to be | 25 | | included in the notice. | 26 | | (c) Upon receipt of the notice that the request meets the |
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| 1 | | reviewability requirements, determining that a request meets | 2 | | the requirements of subsections (b) and (c) of Section 20, the | 3 | | Director health
carrier shall immediately assign an | 4 | | independent review organization from the list of approved | 5 | | independent review organizations compiled and maintained by | 6 | | the Director to conduct the expedited review. In such cases, | 7 | | the following provisions shall apply: | 8 | | (1) The assignment of an approved independent review | 9 | | organization to conduct an external review in accordance | 10 | | with this Section shall be made from those approved | 11 | | independent review organizations qualified to conduct | 12 | | external review as required by Sections 50 and 55 of this | 13 | | Act.
| 14 | | (2) The Director shall immediately notify the health | 15 | | carrier of the name of the assigned independent review | 16 | | organization. Immediately upon receipt from the Director | 17 | | of the name of the independent review organization assigned | 18 | | to conduct the external review assigning an independent | 19 | | review organization to perform an expedited external | 20 | | review , but in no case more than 24 hours after receiving | 21 | | such notice assigning the independent review organization , | 22 | | the health carrier or its designee utilization review | 23 | | organization shall provide or transmit all necessary | 24 | | documents and information considered in making the adverse | 25 | | determination or final adverse determination to the | 26 | | assigned independent review organization electronically or |
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| 1 | | by telephone or facsimile or any other available | 2 | | expeditious method. | 3 | | (3) If the health carrier or its utilization review | 4 | | organization fails to provide the documents and | 5 | | information within the specified timeframe, the assigned | 6 | | independent review organization may terminate the external | 7 | | review and make a decision to reverse the adverse | 8 | | determination or final adverse determination. | 9 | | (4) Within one business day after making the decision | 10 | | to terminate the external review and make a decision to | 11 | | reverse the adverse determination or final adverse | 12 | | determination under item (3) of this subsection (c), the | 13 | | independent review organization shall notify the Director, | 14 | | the health carrier, the covered person , and, if applicable, | 15 | | the covered person's authorized representative of its | 16 | | decision to reverse the adverse determination or final | 17 | | adverse determination .
| 18 | | (d) In addition to the documents and information provided | 19 | | by the health carrier or its utilization review organization | 20 | | and any documents and information provided by the covered | 21 | | person and the covered person's authorized representative, the | 22 | | independent review organization , to the extent the information | 23 | | or documents are available and the independent review | 24 | | organization considers them appropriate, shall consider | 25 | | information as required by subsection (i) of Section 35 of this | 26 | | Act in reaching a decision. |
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| 1 | | (e) As expeditiously as the covered person's medical | 2 | | condition or circumstances requires, but in no event more than | 3 | | 72 hours after the date of receipt of the request for an | 4 | | expedited external review 2 business days after the receipt of | 5 | | all pertinent information , the assigned independent review | 6 | | organization shall: | 7 | | (1) make a decision to uphold or reverse the final | 8 | | adverse determination; and | 9 | | (2) notify the Director, the health carrier, the | 10 | | covered person, the covered person's health care provider, | 11 | | and , if applicable, the covered person's authorized | 12 | | representative, of the decision. | 13 | | (f) In reaching a decision, the assigned independent review | 14 | | organization is not bound by any decisions or conclusions | 15 | | reached during the health carrier's utilization review process | 16 | | or the health carrier's internal appeal grievance process as | 17 | | set forth in the Managed Care Reform and Patient Rights Act .
| 18 | | (g) Upon receipt of notice of a decision reversing the | 19 | | adverse determination or final adverse determination, the | 20 | | health carrier shall immediately approve the coverage that was | 21 | | the subject of the adverse determination or final adverse | 22 | | determination. | 23 | | (h) If the notice provided pursuant to subsection (e) of | 24 | | this Section was not in writing, then within Within 48 hours | 25 | | after the date of providing that the notice required in item | 26 | | (2) of subsection (e) , the assigned independent review |
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| 1 | | organization shall provide written confirmation of the | 2 | | decision to the Director, the health carrier, the covered | 3 | | person, and , if applicable, the covered person's authorized | 4 | | representative including the information set forth in | 5 | | subsection (j) of Section 35 of this Act as applicable. | 6 | | (i) An expedited external review may not be provided for | 7 | | retrospective adverse or final adverse determinations.
| 8 | | (j) The assignment by the Director of an approved | 9 | | independent review organization to conduct an external review | 10 | | in accordance with this Section shall be done on a random basis | 11 | | among those independent review organizations approved by the | 12 | | Director pursuant to this Act. | 13 | | (Source: P.A. 96-857, eff. 7-1-10; revised 9-16-10.) | 14 | | (215 ILCS 180/42 new) | 15 | | Sec. 42. External review of experimental or | 16 | | investigational treatment adverse determinations. | 17 | | (a) Within 4 months after the date of receipt of a notice | 18 | | of an adverse determination or final adverse determination that | 19 | | involves a denial of coverage based on a determination that the | 20 | | health care service or treatment recommended or requested is | 21 | | experimental or investigational, a covered person or the | 22 | | covered person's authorized representative may file a request | 23 | | for an external review with the Director. | 24 | | (b) The following provisions apply to cases concerning | 25 | | expedited external reviews: |
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| 1 | | (1) A covered person or the covered person's authorized | 2 | | representative may make an oral request for an expedited | 3 | | external review of the adverse determination or final | 4 | | adverse determination pursuant to subsection (a) of this | 5 | | Section if the covered person's treating physician | 6 | | certifies, in writing, that the recommended or requested | 7 | | health care service or treatment that is the subject of the | 8 | | request would be significantly less effective if not | 9 | | promptly initiated. | 10 | | (2) Upon receipt of a request for an expedited external | 11 | | review, the Director shall immediately notify the health | 12 | | carrier. | 13 | | (3) The following provisions apply concerning notice: | 14 | | (A) Upon notice of the request for an expedited | 15 | | external review, the health carrier shall immediately | 16 | | determine whether the request meets the reviewability | 17 | | requirements of subsection (d) of this Section. The | 18 | | health carrier shall immediately notify the Director | 19 | | and the covered person and, if applicable, the covered | 20 | | person's authorized representative of its eligibility | 21 | | determination. | 22 | | (B) The Director may specify the form for the | 23 | | health carrier's notice of initial determination under | 24 | | subdivision (A) of this item (3) and any supporting | 25 | | information to be included in the notice. | 26 | | (C) The notice of initial determination under |
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| 1 | | subdivision (A) of this item (3) shall include a | 2 | | statement informing the covered person and, if | 3 | | applicable, the covered person's authorized | 4 | | representative that a health carrier's initial | 5 | | determination that the external review request is | 6 | | ineligible for review may be appealed to the Director. | 7 | | (4) The following provisions apply concerning the | 8 | | Director's determination: | 9 | | (A) The Director may determine that a request is | 10 | | eligible for external review under subsection (d) of | 11 | | this Section notwithstanding a health carrier's | 12 | | initial determination that the request is ineligible | 13 | | and require that it be referred for external review. | 14 | | (B) In making a determination under subdivision | 15 | | (A) of this item (4), the Director's decision shall be | 16 | | made in accordance with the terms of the covered | 17 | | person's health benefit plan, unless such terms are | 18 | | inconsistent with applicable law, and shall be subject | 19 | | to all applicable provisions of this Act. | 20 | | (5) Upon receipt of the notice that the expedited | 21 | | external review request meets the reviewability | 22 | | requirements of subsection (d) of this Section, the | 23 | | Director shall immediately assign an independent review | 24 | | organization to review the expedited request from the list | 25 | | of approved independent review organizations compiled and | 26 | | maintained by the Director and notify the health carrier of |
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| 1 | | the name of the assigned independent review organization. | 2 | | (6) At the time the health carrier receives the notice | 3 | | of the assigned independent review organization, the | 4 | | health carrier or its designee utilization review | 5 | | organization shall provide or transmit all necessary | 6 | | documents and information considered in making the adverse | 7 | | determination or final adverse determination to the | 8 | | assigned independent review organization electronically or | 9 | | by telephone or facsimile or any other available | 10 | | expeditious method. | 11 | | (c) Except for a request for an expedited external review | 12 | | made pursuant to subsection (b) of this Section, within one | 13 | | business day after the date of receipt of a request for | 14 | | external review, the Director shall send a copy of the request | 15 | | to the health carrier. | 16 | | (d) Within 5 business days following the date of receipt of | 17 | | the external review request, the health carrier shall complete | 18 | | a preliminary review of the request to determine whether: | 19 | | (1) the individual is or was a covered person in the | 20 | | health benefit plan at the time the health care service was | 21 | | recommended or requested or, in the case of a retrospective | 22 | | review, at the time the health care service was provided; | 23 | | (2) the recommended or requested health care service or | 24 | | treatment that is the subject of the adverse determination | 25 | | or final adverse determination is a covered benefit under | 26 | | the covered person's health benefit plan except for the |
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| 1 | | health carrier's determination that the service or | 2 | | treatment is experimental or investigational for a | 3 | | particular medical condition and is not explicitly listed | 4 | | as an excluded benefit under the covered person's health | 5 | | benefit plan with the health carrier; | 6 | | (3) the covered person's health care provider has | 7 | | certified that one of the following situations is | 8 | | applicable: | 9 | | (A) standard health care services or treatments | 10 | | have not been effective in improving the condition of | 11 | | the covered person; | 12 | | (B) standard health care services or treatments | 13 | | are not medically appropriate for the covered person; | 14 | | or | 15 | | (C) there is no available standard health care | 16 | | service or treatment covered by the health carrier that | 17 | | is more beneficial than the recommended or requested | 18 | | health care service or treatment; | 19 | | (4) the covered person's health care provider: | 20 | | (A) has recommended a health care service or | 21 | | treatment that the physician certifies, in writing, is | 22 | | likely to be more beneficial to the covered person, in | 23 | | the physician's opinion, than any available standard | 24 | | health care services or treatments; or | 25 | | (B) who is a licensed, board certified or board | 26 | | eligible physician qualified to practice in the area of |
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| 1 | | medicine appropriate to treat the covered person's | 2 | | condition, has certified in writing that | 3 | | scientifically valid studies using accepted protocols | 4 | | demonstrate that the health care service or treatment | 5 | | requested by the covered person that is the subject of | 6 | | the adverse determination or final adverse | 7 | | determination is likely to be more beneficial to the | 8 | | covered person than any available standard health care | 9 | | services or treatments; | 10 | | (5) the covered person has exhausted the health | 11 | | carrier's internal appeal process, unless the covered | 12 | | person is not required to exhaust the health carrier's | 13 | | internal appeal process pursuant to Section 30 of this Act; | 14 | | and | 15 | | (6) the covered person has provided all the information | 16 | | and forms required to process an external review, as | 17 | | specified in this Act. | 18 | | (e) The following provisions apply concerning requests: | 19 | | (1) Within one business day after completion of the | 20 | | preliminary review, the health carrier shall notify the | 21 | | Director and covered person and, if applicable, the covered | 22 | | person's authorized representative in writing whether the | 23 | | request is complete and eligible for external review. | 24 | | (2) If the request: | 25 | | (A) is not complete, then the health carrier shall | 26 | | inform the Director and the covered person and, if |
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| 1 | | applicable, the covered person's authorized | 2 | | representative in writing and include in the notice | 3 | | what information or materials are required by this Act | 4 | | to make the request complete; or | 5 | | (B) is not eligible for external review, then the | 6 | | health carrier shall inform the Director and the | 7 | | covered person and, if applicable, the covered | 8 | | person's authorized representative in writing and | 9 | | include in the notice the reasons for its | 10 | | ineligibility. | 11 | | (3) The Department may specify the form for the health | 12 | | carrier's notice of initial determination under this | 13 | | subsection (e) and any supporting information to be | 14 | | included in the notice. | 15 | | (4) The notice of initial determination of | 16 | | ineligibility shall include a statement informing the | 17 | | covered person and, if applicable, the covered person's | 18 | | authorized representative that a health carrier's initial | 19 | | determination that the external review request is | 20 | | ineligible for review may be appealed to the Director by | 21 | | filing a complaint with the Director. | 22 | | (5) Notwithstanding a health carrier's initial | 23 | | determination that the request is ineligible for external | 24 | | review, the Director may determine that a request is | 25 | | eligible for external review and require that it be | 26 | | referred for external review. In making such |
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| 1 | | determination, the Director's decision shall be in | 2 | | accordance with the terms of the covered person's health | 3 | | benefit plan, unless such terms are inconsistent with | 4 | | applicable law, and shall be subject to all applicable | 5 | | provisions of this Act. | 6 | | (f) Whenever a request for external review is determined | 7 | | eligible for external review, the health carrier shall notify | 8 | | the Director and the covered person and, if applicable, the | 9 | | covered person's authorized representative. | 10 | | (g) Whenever the Director receives notice that a request is | 11 | | eligible for external review following the preliminary review | 12 | | conducted pursuant to this Section, within one business day | 13 | | after the date of receipt of the notice, the Director shall: | 14 | | (1) assign an independent review organization from the | 15 | | list of approved independent review organizations compiled | 16 | | and maintained by the Director pursuant to this Act and | 17 | | notify the health carrier of the name of the assigned | 18 | | independent review organization; and | 19 | | (2) notify in writing the covered person and, if | 20 | | applicable, the covered person's authorized representative | 21 | | of the request's eligibility and acceptance for external | 22 | | review and the name of the independent review organization. | 23 | | The Director shall include in the notice provided to the | 24 | | covered person and, if applicable, the covered person's | 25 | | authorized representative a statement that the covered person | 26 | | or the covered person's authorized representative may, within 5 |
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| 1 | | business days following the date of receipt of the notice | 2 | | provided pursuant to item (2) of this subsection (g), submit in | 3 | | writing to the assigned independent review organization | 4 | | additional information that the independent review | 5 | | organization shall consider when conducting the external | 6 | | review. The independent review organization is not required to, | 7 | | but may, accept and consider additional information submitted | 8 | | after 5 business days. | 9 | | (h) The following provisions apply concerning assignments | 10 | | and clinical reviews: | 11 | | (1) Within one business day after the receipt of the | 12 | | notice of assignment to conduct the external review | 13 | | pursuant to subsection (g) of this Section, the assigned | 14 | | independent review organization shall select one or more | 15 | | clinical reviewers, as it determines is appropriate, | 16 | | pursuant to item (2) of this subsection (h) to conduct the | 17 | | external review. | 18 | | (2) The provisions of this item (2) apply concerning | 19 | | the selection of reviewers: | 20 | | (A) In selecting clinical reviewers pursuant to | 21 | | item (1) of this subsection (h), the assigned | 22 | | independent review organization shall select | 23 | | physicians or other health care professionals who meet | 24 | | the minimum qualifications described in Section 55 of | 25 | | this Act and, through clinical experience in the past 3 | 26 | | years, are experts in the treatment of the covered |
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| 1 | | person's condition and knowledgeable about the | 2 | | recommended or requested health care service or | 3 | | treatment. | 4 | | (B) Neither the covered person, the covered | 5 | | person's authorized representative, if applicable, nor | 6 | | the health carrier shall choose or control the choice | 7 | | of the physicians or other health care professionals to | 8 | | be selected to conduct the external review. | 9 | | (3) In accordance with subsection (l) of this Section, | 10 | | each clinical reviewer shall provide a written opinion to | 11 | | the assigned independent review organization on whether | 12 | | the recommended or requested health care service or | 13 | | treatment should be covered. | 14 | | (4) In reaching an opinion, clinical reviewers are not | 15 | | bound by any decisions or conclusions reached during the | 16 | | health carrier's utilization review process or the health | 17 | | carrier's internal appeal process. | 18 | | (i) Within 5 business days after the date of receipt of the | 19 | | notice provided pursuant to subsection (g) of this Section, the | 20 | | health carrier or its designee utilization review organization | 21 | | shall provide to the assigned independent review organization | 22 | | the documents and any information considered in making the | 23 | | adverse determination or final adverse determination; in such | 24 | | cases, the following provisions shall apply: | 25 | | (1) Except as provided in item (2) of this subsection | 26 | | (i), failure by the health carrier or its utilization |
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| 1 | | review organization to provide the documents and | 2 | | information within the specified time frame shall not delay | 3 | | the conduct of the external review. | 4 | | (2) If the health carrier or its utilization review | 5 | | organization fails to provide the documents and | 6 | | information within the specified time frame, the assigned | 7 | | independent review organization may terminate the external | 8 | | review and make a decision to reverse the adverse | 9 | | determination or final adverse determination. | 10 | | (3) Immediately upon making the decision to terminate | 11 | | the external review and make a decision to reverse the | 12 | | adverse determination or final adverse determination under | 13 | | item (2) of this subsection (i), the independent review | 14 | | organization shall notify the Director, the health | 15 | | carrier, the covered person, and, if applicable, the | 16 | | covered person's authorized representative of its decision | 17 | | to reverse the adverse determination. | 18 | | (j) Upon receipt of the information from the health carrier | 19 | | or its utilization review organization, each clinical reviewer | 20 | | selected pursuant to subsection (h) of this Section shall | 21 | | review all of the information and documents and any other | 22 | | information submitted in writing to the independent review | 23 | | organization by the covered person and the covered person's | 24 | | authorized representative. | 25 | | (k) Upon receipt of any information submitted by the | 26 | | covered person or the covered person's authorized |
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| 1 | | representative, the independent review organization shall | 2 | | forward the information to the health carrier within one | 3 | | business day. In such cases, the following provisions shall | 4 | | apply: | 5 | | (1) Upon receipt of the information, if any, the health | 6 | | carrier may reconsider its adverse determination or final | 7 | | adverse determination that is the subject of the external | 8 | | review. | 9 | | (2) Reconsideration by the health carrier of its | 10 | | adverse determination or final adverse determination shall | 11 | | not delay or terminate the external review. | 12 | | (3) The external review may be terminated only if the | 13 | | health carrier decides, upon completion of its | 14 | | reconsideration, to reverse its adverse determination or | 15 | | final adverse determination and provide coverage or | 16 | | payment for the health care service that is the subject of | 17 | | the adverse determination or final adverse determination. | 18 | | In such cases, the following provisions shall apply: | 19 | | (A) Immediately upon making its decision to | 20 | | reverse its adverse determination or final adverse | 21 | | determination, the health carrier shall notify the | 22 | | Director, the covered person and, if applicable, the | 23 | | covered person's authorized representative, and the | 24 | | assigned independent review organization in writing of | 25 | | its decision. | 26 | | (B) Upon notice from the health carrier that the |
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| 1 | | health carrier has made a decision to reverse its | 2 | | adverse determination or final adverse determination, | 3 | | the assigned independent review organization shall | 4 | | terminate the external review. | 5 | | (l) The following provisions apply concerning clinical | 6 | | review opinions: | 7 | | (1) Except as provided in item (3) of this subsection | 8 | | (l), within 20 days after being selected in accordance with | 9 | | subsection (h) of this Section to conduct the external | 10 | | review, each clinical reviewer shall provide an opinion to | 11 | | the assigned independent review organization on whether | 12 | | the recommended or requested health care service or | 13 | | treatment should be covered. | 14 | | (2) Except for an opinion provided pursuant to item (3) | 15 | | of this subsection (l), each clinical reviewer's opinion | 16 | | shall be in writing and include the following information: | 17 | | (A) a description of the covered person's medical | 18 | | condition; | 19 | | (B) a description of the indicators relevant to | 20 | | determining whether there is sufficient evidence to | 21 | | demonstrate that the recommended or requested health | 22 | | care service or treatment is more likely than not to be | 23 | | beneficial to the covered person than any available | 24 | | standard health care services or treatments and the | 25 | | adverse risks of the recommended or requested health | 26 | | care service or treatment would not be substantially |
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| 1 | | increased over those of available standard health care | 2 | | services or treatments; | 3 | | (C) a description and analysis of any medical or | 4 | | scientific evidence considered in reaching the | 5 | | opinion; | 6 | | (D) a description and analysis of any | 7 | | evidence-based standard; and | 8 | | (E) information on whether the reviewer's | 9 | | rationale for the opinion is based on clause (A) or (B) | 10 | | of item (5) of subsection (m) of this Section. | 11 | | (3) The provisions of this item (3) apply concerning | 12 | | the timing of opinions: | 13 | | (A) For an expedited external review, each | 14 | | clinical reviewer shall provide an opinion orally or in | 15 | | writing to the assigned independent review | 16 | | organization as expeditiously as the covered person's | 17 | | medical condition or circumstances requires, but in no | 18 | | event more than 5 calendar days after being selected in | 19 | | accordance with subsection (h) of this Section. | 20 | | (B) If the opinion provided pursuant to | 21 | | subdivision (A) of this item (3) was not in writing, | 22 | | then within 48 hours following the date the opinion was | 23 | | provided, the clinical reviewer shall provide written | 24 | | confirmation of the opinion to the assigned | 25 | | independent review organization and include the | 26 | | information required under item (2) of this subsection |
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| 1 | | (l). | 2 | | (m) In addition to the documents and information provided | 3 | | by the health carrier or its utilization review organization | 4 | | and the covered person and the covered person's authorized | 5 | | representative, if any, each clinical reviewer selected | 6 | | pursuant to subsection (h) of this Section, to the extent the | 7 | | information or documents are available and the clinical | 8 | | reviewer considers appropriate, shall consider the following | 9 | | in reaching a decision: | 10 | | (1) the covered person's pertinent medical records; | 11 | | (2) the covered person's health care provider's | 12 | | recommendation; | 13 | | (3) consulting reports from appropriate health care | 14 | | providers and other documents submitted by the health | 15 | | carrier or its designee utilization review organization, | 16 | | the covered person, the covered person's authorized | 17 | | representative, or the covered person's treating physician | 18 | | or health care professional; | 19 | | (4) the terms of coverage under the covered person's | 20 | | health benefit plan with the health carrier to ensure that, | 21 | | but for the health carrier's determination that the | 22 | | recommended or requested health care service or treatment | 23 | | that is the subject of the opinion is experimental or | 24 | | investigational, the reviewer's opinion is not contrary to | 25 | | the terms of coverage under the covered person's health | 26 | | benefit plan with the health carrier; and |
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| 1 | | (5) whether (A) the recommended or requested health | 2 | | care service or treatment has been approved by the federal | 3 | | Food and Drug Administration, if applicable, for the | 4 | | condition or (B) medical or scientific evidence or | 5 | | evidence-based standards demonstrate that the expected | 6 | | benefits of the recommended or requested health care | 7 | | service or treatment is more likely than not to be | 8 | | beneficial to the covered person than any available | 9 | | standard health care service or treatment and the adverse | 10 | | risks of the recommended or requested health care service | 11 | | or treatment would not be substantially increased over | 12 | | those of available standard health care services or | 13 | | treatments. | 14 | | (n) The following provisions apply concerning decisions, | 15 | | notices, and recommendations: | 16 | | (1) The provisions of this item (1) apply concerning | 17 | | decisions and notices: | 18 | | (A) Except as provided in subdivision (B) of this | 19 | | item (1), within 20 days after the date it receives the | 20 | | opinion of each clinical reviewer, the assigned | 21 | | independent review organization, in accordance with | 22 | | item (2) of this subsection (n), shall make a decision | 23 | | and provide written notice of the decision to the | 24 | | Director, the health carrier, the covered person, and | 25 | | the covered person's authorized representative, if | 26 | | applicable. |
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| 1 | | (B) For an expedited external review, within 48 | 2 | | hours after the date it receives the opinion of each | 3 | | clinical reviewer, the assigned independent review | 4 | | organization, in accordance with item (2) of this | 5 | | subsection (n), shall make a decision and provide | 6 | | notice of the decision orally or in writing to the | 7 | | Director, the health carrier, the covered person, and | 8 | | the covered person's authorized representative, if | 9 | | applicable. If such notice is not in writing, within 48 | 10 | | hours after the date of providing that notice, the | 11 | | assigned independent review organization shall provide | 12 | | written confirmation of the decision to the Director, | 13 | | the health carrier, the covered person, and the covered | 14 | | person's authorized representative, if applicable. | 15 | | (2) The provisions of this item (2) apply concerning | 16 | | recommendations: | 17 | | (A) If a majority of the clinical reviewers | 18 | | recommend that the recommended or requested health | 19 | | care service or treatment should be covered, then the | 20 | | independent review organization shall make a decision | 21 | | to reverse the health carrier's adverse determination | 22 | | or final adverse determination. | 23 | | (B) If a majority of the clinical reviewers | 24 | | recommend that the recommended or requested health | 25 | | care service or treatment should not be covered, the | 26 | | independent review organization shall make a decision |
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| 1 | | to uphold the health carrier's adverse determination | 2 | | or final adverse determination. | 3 | | (C) The provisions of this subdivision (C) apply to | 4 | | cases in which the clinical reviewers are evenly split: | 5 | | (i) If the clinical reviewers are evenly split | 6 | | as to whether the recommended or requested health | 7 | | care service or treatment should be covered, then | 8 | | the independent review organization shall obtain | 9 | | the opinion of an additional clinical reviewer in | 10 | | order for the independent review organization to | 11 | | make a decision based on the opinions of a majority | 12 | | of the clinical reviewers pursuant to subdivision | 13 | | (A) or (B) of this item (2). | 14 | | (ii) The additional clinical reviewer selected | 15 | | under clause (i) of this subdivision (C) shall use | 16 | | the same information to reach an opinion as the | 17 | | clinical reviewers who have already submitted | 18 | | their opinions. | 19 | | (iii) The selection of the additional clinical | 20 | | reviewer under this subdivision (C) shall not | 21 | | extend the time within which the assigned | 22 | | independent review organization is required to | 23 | | make a decision based on the opinions of the | 24 | | clinical reviewers. | 25 | | (o) The independent review organization shall include in | 26 | | the notice provided pursuant to subsection (n) of this Section: |
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| 1 | | (1) a general description of the reason for the request | 2 | | for external review; | 3 | | (2) the written opinion of each clinical reviewer, | 4 | | including the recommendation of each clinical reviewer as | 5 | | to whether the recommended or requested health care service | 6 | | or treatment should be covered and the rationale for the | 7 | | reviewer's recommendation; | 8 | | (3) the date the independent review organization | 9 | | received the assignment from the Director to conduct the | 10 | | external review; | 11 | | (4) the time period during which the external review | 12 | | was conducted; | 13 | | (5) the date of its decision; | 14 | | (6) the principal reason or reasons for its decision; | 15 | | and | 16 | | (7) the rationale for its decision. | 17 | | (p) Upon receipt of a notice of a decision reversing the | 18 | | adverse determination or final adverse determination, the | 19 | | health carrier shall immediately approve the coverage that was | 20 | | the subject of the adverse determination or final adverse | 21 | | determination. | 22 | | (q) The assignment by the Director of an approved | 23 | | independent review organization to conduct an external review | 24 | | in accordance with this Section shall be done on a random basis | 25 | | among those independent review organizations approved by the | 26 | | Director pursuant to this Act. |
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| 1 | | (215 ILCS 180/55)
| 2 | | Sec. 55. Minimum qualifications for independent review | 3 | | organizations.
| 4 | | (a) To be approved to conduct external reviews, an | 5 | | independent review organization shall have and maintain | 6 | | written policies and procedures that govern all aspects of both | 7 | | the standard external review process and the expedited external | 8 | | review process set forth in this Act that include, at a | 9 | | minimum: | 10 | | (1) a quality assurance mechanism that ensures that: | 11 | | (A) external reviews are conducted within the | 12 | | specified timeframes and required notices are provided | 13 | | in a timely manner; | 14 | | (B) selection of qualified and impartial clinical | 15 | | reviewers to conduct external reviews on behalf of the | 16 | | independent review organization and suitable matching | 17 | | of reviewers to specific cases and that the independent | 18 | | review organization employs or contracts with an | 19 | | adequate number of clinical reviewers to meet this | 20 | | objective; | 21 | | (C) for adverse determinations involving | 22 | | experimental or investigational treatments, in | 23 | | assigning clinical reviewers, the independent review | 24 | | organization selects physicians or other health care | 25 | | professionals who, through clinical experience in the |
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| 1 | | past 3 years, are experts in the treatment of the | 2 | | covered person's condition and knowledgeable about the | 3 | | recommended or requested health care service or | 4 | | treatment; | 5 | | (D) the health carrier, the covered person, and the | 6 | | covered person's authorized representative shall not | 7 | | choose or control the choice of the physicians or other | 8 | | health care professionals to be selected to conduct the | 9 | | external review; | 10 | | (E) confidentiality of medical and treatment | 11 | | records and clinical review criteria; and | 12 | | (F) any person employed by or under contract with | 13 | | the independent review organization adheres to the | 14 | | requirements of this Act; | 15 | | (2) a toll-free telephone service operating on a | 16 | | 24-hour-day, 7-day-a-week basis that accepts, receives, | 17 | | and records information related to external reviews and | 18 | | provides appropriate instructions; and | 19 | | (3) an agreement to maintain and provide to the | 20 | | Director the information set out in Section 70 of this Act. | 21 | | (b) All clinical reviewers assigned by an independent | 22 | | review organization to conduct external reviews shall be | 23 | | physicians or other appropriate health care providers who meet | 24 | | the following minimum qualifications:
| 25 | | (1) be an expert in the treatment of the covered | 26 | | person's medical condition that is the subject of the |
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| 1 | | external review; | 2 | | (2) be knowledgeable about the recommended health care | 3 | | service or treatment through recent or current actual | 4 | | clinical experience treating patients with the same or | 5 | | similar medical condition of the covered person; | 6 | | (3) hold a non-restricted license in a state of the | 7 | | United States and, for physicians, a current certification | 8 | | by a recognized American medical specialty board in the | 9 | | area or areas appropriate to the subject of the external | 10 | | review; and | 11 | | (4) have no history of disciplinary actions or | 12 | | sanctions, including loss of staff privileges or | 13 | | participation restrictions, that have been taken or are | 14 | | pending by any hospital, governmental agency or unit, or | 15 | | regulatory body that raise a substantial question as to the | 16 | | clinical reviewer's physical, mental, or professional | 17 | | competence or moral character. | 18 | | (c) In addition to the requirements set forth in subsection | 19 | | (a), an independent review organization may not own or control, | 20 | | be a subsidiary of, or in any way be owned, or controlled by, | 21 | | or exercise control with a health benefit plan, a national, | 22 | | State, or local trade association of health benefit plans, or a | 23 | | national, State, or local trade association of health care | 24 | | providers. | 25 | | (d) Conflicts of interest prohibited.
In addition to the | 26 | | requirements set forth in subsections (a), (b), and (c) of this |
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| 1 | | Section, to be approved pursuant to this Act to conduct an | 2 | | external review of a specified case, neither the independent | 3 | | review organization selected to conduct the external review nor | 4 | | any clinical reviewer assigned by the independent organization | 5 | | to conduct the external review may have a material | 6 | | professional, familial or financial conflict of interest with | 7 | | any of the following: | 8 | | (1) the health carrier that is the subject of the | 9 | | external review; | 10 | | (2) the covered person whose treatment is the subject | 11 | | of the external review or the covered person's authorized | 12 | | representative; | 13 | | (3) any officer, director or management employee of the | 14 | | health carrier that is the subject of the external review; | 15 | | (4) the health care provider, the health care | 16 | | provider's medical group or independent practice | 17 | | association recommending the health care service or | 18 | | treatment that is the subject of the external review; | 19 | | (5) the facility at which the recommended health care | 20 | | service or treatment would be provided; or | 21 | | (6) the developer or manufacturer of the principal | 22 | | drug, device, procedure, or other therapy being | 23 | | recommended for the covered person whose treatment is the | 24 | | subject of the external review.
| 25 | | (e) An independent review organization that is accredited | 26 | | by a nationally recognized private accrediting entity that has |
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| 1 | | independent review accreditation standards that the Director | 2 | | has determined are equivalent to or exceed the minimum | 3 | | qualifications of this Section shall be presumed to be in | 4 | | compliance with this Section and shall be eligible for approval | 5 | | under this Act. | 6 | | (f) An independent review organization shall be unbiased. | 7 | | An independent review organization shall establish and | 8 | | maintain written procedures to ensure that it is unbiased in | 9 | | addition to any other procedures required under this Section. | 10 | | (g) Nothing in this Act precludes or shall be interpreted | 11 | | to preclude a health carrier from contracting with approved | 12 | | independent review organizations to conduct external reviews | 13 | | assigned to it from such health carrier .
| 14 | | (Source: P.A. 96-857, eff. 7-1-10 .) | 15 | | (215 ILCS 180/65)
| 16 | | Sec. 65. External review reporting requirements. | 17 | | (a) Each health carrier shall maintain written records in | 18 | | the aggregate , by state, and for each type of health benefit | 19 | | plan offered by the health carrier on all requests for external | 20 | | review that the health carrier received notice from the | 21 | | Director for each calendar year and submit a report to the | 22 | | Director in the format specified by the Director by March 1 of | 23 | | each year. | 24 | | (a-5) An independent review organization assigned pursuant | 25 | | to this Act to conduct an external review shall maintain |
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| 1 | | written records in the aggregate by state and by health carrier | 2 | | on all requests for external review for which it conducted an | 3 | | external review during a calendar year and submit a report in | 4 | | the format specified by the Director by March 1 of each year. | 5 | | (a-10) The report required by subsection (a-5) shall | 6 | | include in the aggregate by state, and for each health carrier: | 7 | | (1) the total number of requests for external review; | 8 | | (2) the number of requests for external review resolved | 9 | | and, of those resolved, the number resolved upholding the | 10 | | adverse determination or final adverse determination and | 11 | | the number resolved reversing the adverse determination or | 12 | | final adverse determination; | 13 | | (3) the average length of time for resolution; | 14 | | (4) a summary of the types of coverages or cases for | 15 | | which an external review was sought, as provided in the | 16 | | format required by the Director; | 17 | | (5) the number of external reviews that were terminated | 18 | | as the result of a reconsideration by the health carrier of | 19 | | its adverse determination or final adverse determination | 20 | | after the receipt of additional information from the | 21 | | covered person or the covered person's authorized | 22 | | representative; and | 23 | | (6) any other information the Director may request or | 24 | | require. | 25 | | (a-15) The independent review organization shall retain | 26 | | the written records required pursuant to this Section for at |
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| 1 | | least 3 years. | 2 | | (b) The report required under subsection (a) of this | 3 | | Section shall include in the aggregate , by state, and by type | 4 | | of health benefit plan :
| 5 | | (1) the total number of requests for external review; | 6 | | (2) the total number of requests for expedited external | 7 | | review;
| 8 | | (3) the total number of requests for external review | 9 | | denied; | 10 | | (4) the number of requests for external review | 11 | | resolved, including: | 12 | | (A) the number of requests for external review | 13 | | resolved upholding the adverse determination or final | 14 | | adverse determination; | 15 | | (B) the number of requests for external review | 16 | | resolved reversing the adverse determination or final | 17 | | adverse determination; | 18 | | (C) the number of requests for expedited external | 19 | | review resolved upholding the adverse determination or | 20 | | final adverse determination; and | 21 | | (D) the number of requests for expedited external | 22 | | review resolved reversing the adverse determination or | 23 | | final adverse determination; | 24 | | (5) the average length of time for resolution for an | 25 | | external review; | 26 | | (6) the average length of time for resolution for an |
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| 1 | | expedited external review; | 2 | | (7) a summary of the types of coverages or cases for | 3 | | which an external review was sought, as specified below:
| 4 | | (A) denial of care or treatment (dissatisfaction | 5 | | regarding prospective non-authorization of a request | 6 | | for care or treatment recommended by a provider | 7 | | excluding diagnostic procedures and referral requests; | 8 | | partial approvals and care terminations are also | 9 | | considered to be denials); | 10 | | (B) denial of diagnostic procedure | 11 | | (dissatisfaction regarding prospective | 12 | | non-authorization of a request for a diagnostic | 13 | | procedure recommended by a provider; partial approvals | 14 | | are also considered to be denials); | 15 | | (C) denial of referral request (dissatisfaction | 16 | | regarding non-authorization of a request for a | 17 | | referral to another provider recommended by a PCP); | 18 | | (D) claims and utilization review (dissatisfaction | 19 | | regarding the concurrent or retrospective evaluation | 20 | | of the coverage, medical necessity, efficiency or | 21 | | appropriateness of health care services or treatment | 22 | | plans; prospective "Denials of care or treatment", | 23 | | "Denials of diagnostic procedures" and "Denials of | 24 | | referral requests" should not be classified in this | 25 | | category, but the appropriate one above);
| 26 | | (8) the number of external reviews that were terminated |
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| 1 | | as the result of a reconsideration by the health carrier of | 2 | | its adverse determination or final adverse determination | 3 | | after the receipt of additional information from the | 4 | | covered person or the covered person's authorized | 5 | | representative; and | 6 | | (9) any other information the Director may request or | 7 | | require.
| 8 | | (Source: P.A. 96-857, eff. 7-1-10 .) | 9 | | (215 ILCS 180/75)
| 10 | | Sec. 75. Disclosure requirements. | 11 | | (a) Each health carrier shall include a description of the | 12 | | external review procedures in, or attached to, the policy, | 13 | | certificate, membership booklet, and outline of coverage or | 14 | | other evidence of coverage it provides to covered persons. | 15 | | (b) The description required under subsection (a) of this | 16 | | Section shall include a statement that informs the covered | 17 | | person of the right of the covered person to file a request for | 18 | | an external review of an adverse determination or final adverse | 19 | | determination with the Director health carrier . The statement | 20 | | shall explain that external review is available when the | 21 | | adverse determination or final adverse determination involves | 22 | | an issue of medical necessity, appropriateness, health care | 23 | | setting, level of care, or effectiveness. The statement shall | 24 | | include the toll-free telephone number and address of the | 25 | | Office of Consumer Health Insurance within the Department of |
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| 1 | | Insurance.
| 2 | | (Source: P.A. 96-857, eff. 7-1-10 .) | 3 | | (215 ILCS 180/80 new) | 4 | | Sec. 80. Administration and enforcement. | 5 | | (a) The Director of Insurance may adopt rules necessary to | 6 | | implement the Department's responsibilities under this Act. | 7 | | (b) The Director is authorized to make use of any of the | 8 | | powers established under the Illinois Insurance Code to enforce | 9 | | the laws of this State. This includes but is not limited to, | 10 | | the Director's administrative authority to investigate, issue | 11 | | subpoenas, conduct depositions and hearings, issue orders, | 12 | | including, without limitation, orders pursuant to Article XII | 13 | | 1/2 and Section 401.1 of the Illinois Insurance Code, and | 14 | | impose penalties.
| 15 | | Section 99. Effective date. This Act takes effect on July | 16 | | 1, 2011.
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