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(215 ILCS 134/85)
Utilization review program registration.
(a) No person may conduct a utilization review program in this State unless
once every 2 years the person
registers the utilization review program with the Department and certifies
compliance with the Health
Utilization Management Standards of the American Accreditation Healthcare
Commission (URAC) sufficient to achieve American Accreditation Healthcare
Commission (URAC) accreditation or submits evidence of accreditation by the
Accreditation Healthcare Commission (URAC) for its Health Utilization
Nothing in this Act shall be construed to require a health care plan or its
subcontractors to become American Accreditation Healthcare Commission (URAC)
(b) In addition, the Director of the Department, in consultation with the
Director of the Department of Public Health, may certify alternative
utilization review standards of national accreditation organizations or
entities in order for plans to comply with this Section. Any alternative
utilization review standards shall meet or exceed those standards required
under subsection (a).
(b-5) The Department shall recognize the Accreditation Association for Ambulatory Health Care among the list of accreditors from which utilization organizations may receive accreditation and qualify for reduced registration and renewal fees.
(c) The provisions of this Section do not apply to:
(1) persons providing utilization review program
services only to the federal government;
(2) self-insured health plans under the federal
Employee Retirement Income Security Act of 1974, however, this Section does apply to persons conducting a utilization review program on behalf of these health plans;
(3) hospitals and medical groups performing
utilization review activities for internal purposes unless the utilization review program is conducted for another person.
Nothing in this Act prohibits a health care plan or other entity from
contractually requiring an entity designated in item (3) of this subsection
to adhere to
utilization review program requirements of
(d) This registration shall include submission of all of the following
regarding utilization review program activities:
(1) The name, address, and telephone number of the
utilization review programs.
(2) The organization and governing structure of the
utilization review programs.
(3) The number of lives for which utilization review
is conducted by each utilization review program.
(4) Hours of operation of each utilization review
(5) Description of the grievance process for each
utilization review program.
(6) Number of covered lives for which utilization
review was conducted for the previous calendar year for each utilization review program.
(7) Written policies and procedures for protecting
confidential information according to applicable State and federal laws for each utilization review program.
(e) (1) A utilization review program shall have written procedures for
assuring that patient-specific information obtained during the process of
utilization review will be:
(A) kept confidential in accordance with applicable
State and federal laws; and
(B) shared only with the enrollee, the enrollee's
designee, the enrollee's health care provider, and those who are authorized by law to receive the information.
Summary data shall not be considered confidential if it does not provide
information to allow identification of individual patients or health care
(2) Only a health care professional may make
determinations regarding the medical necessity of health care services during the course of utilization review.
(3) When making retrospective reviews, utilization
review programs shall base reviews solely on the medical information available to the attending physician or ordering provider at the time the health care services were provided.
(4) When making prospective, concurrent, and
retrospective determinations, utilization review programs shall collect only information that is necessary to make the determination and shall not routinely require health care providers to numerically code diagnoses or procedures to be considered for certification, unless required under State or federal Medicare or Medicaid rules or regulations, but may request such code if available, or routinely request copies of medical records of all enrollees reviewed. During prospective or concurrent review, copies of medical records shall only be required when necessary to verify that the health care services subject to review are medically necessary. In these cases, only the necessary or relevant sections of the medical record shall be required.
(f) If the Department finds that a utilization review program is
not in compliance with this Section, the Department shall issue a corrective
action plan and allow a reasonable amount of time for compliance with the plan.
If the utilization review program does not come into compliance, the
Department may issue a cease and desist order. Before issuing a cease and
desist order under this Section, the Department shall provide the
utilization review program with a written notice of the reasons for the
order and allow a reasonable amount of time to supply additional information
demonstrating compliance with requirements of this Section and to request a
hearing. The hearing notice shall be sent by certified mail, return receipt
requested, and the hearing shall be conducted in accordance with the Illinois
Administrative Procedure Act.
(g) A utilization review program subject to a corrective action may continue
to conduct business
until a final decision has been issued by the Department.
(h) Any adverse determination made by a health care plan or its
subcontractors may be appealed
in accordance with subsection (f) of Section 45.
(i) The Director may by rule establish a registration fee for each person
conducting a utilization review program. All fees paid to and collected by the
Director under this Section shall be deposited into
the Insurance Producer Administration Fund.
(Source: P.A. 99-111, eff. 1-1-16