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(20 ILCS 2215/5-1) (from Ch. 111 1/2, par. 6505-1)
Sec. 5-1. Mandatory Utilization Review.
(a) Except as prohibited by
Federal law or regulations, any third party payor shall have the option
to require utilization review for hospital admissions and continued hospital
stays, except for the Department of Healthcare and Family Services for payment of hospital
services for recipients of assistance under Articles V, VI, and VII of the
Illinois Public Aid Code. The payor shall have the option to contract
with a medical peer review organization, provided that the organization
is at minimum, composed of 10% of area physicians, or the hospital to perform
utilization review or to conduct its own utilization review. A medical
peer review organization, as defined, may also contract with hospitals to
perform reviews on a delegated basis. The utilization review process shall
provide for the timely notification of patients by the third party payor
or review organization that further services are deemed inappropriate or
medically unnecessary. Such notification shall inform the patient that
his third party payor will cease coverage after a stated period from the
date of the notification. No third party payor shall be liable for charges
for health care services rendered by a hospital subsequent to the end of
the notification period.
Nothing in this Section shall be construed as authorizing any person or
third party payor, other than through the use of physicians licensed to
practice medicine in all of its branches or other licensed health care
professionals under the supervision of said physicians, to conduct utilization
review.
(b) All costs associated with utilization review under this section shall
be billed to and paid by the third party payor ordering the review.
(c) Any third party payor for hospital services may contract with a hospital
for a program of utilization review different than that required by this
subsection, which contract may provide for the withholding and denial of
payment for hospital services to a beneficiary, when such treatment is found
in the course of utilization review to have been inappropriate and unwarranted
in the case of that beneficiary.
(d) All records and reports arising as a result of this subsection shall
be strictly privileged and confidential, as provided under Part 21 of
Article VIII of the Code of Civil Procedure.
(Source: P.A. 95-331, eff. 8-21-07.)
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