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(215 ILCS 180/40) Sec. 40. Expedited external review. (a) A covered person or a covered person's authorized representative may file a request for an expedited external review with the Director either orally or in writing: (1) immediately after the date of receipt of a notice |
| prior to a final adverse determination as provided by subsection (b) of Section 20 of this Act;
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(2) immediately after the date of receipt of a notice
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| upon final adverse determination as provided by subsection (c) of Section 20 of this Act; or
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(3) if a health carrier fails to provide a decision
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| on request for an expedited internal appeal within 48 hours as provided by item (2) of Section 30 of this Act.
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(b) Upon receipt of a request for an expedited external review, the Director shall immediately send a copy of the request to the health carrier. Immediately upon receipt of the request for an expedited external review, the health carrier shall determine whether the request meets the reviewability requirements set forth in subsection (b) of Section 35. In such cases, the following provisions shall apply:
(1) The health carrier shall immediately notify the
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| Director, the covered person, and, if applicable, the covered person's authorized representative of its eligibility determination.
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(2) The notice of initial determination shall
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| include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that an external review request is ineligible for review may be appealed to the Director.
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(3) The Director may determine that a request is
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| eligible for expedited external review notwithstanding a health carrier's initial determination that the request is ineligible and require that it be referred for external review.
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(4) In making a determination under item (3) of this
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| subsection (b), the Director's decision shall be made in accordance with the terms of the covered person's health benefit plan, unless such terms are inconsistent with applicable law, and shall be subject to all applicable provisions of this Act.
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(5) The Director may specify the form for the health
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| carrier's notice of initial determination under this subsection (b) and any supporting information to be included in the notice.
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(c) Upon receipt of the notice that the request meets the reviewability requirements, the Director shall immediately assign an independent review organization from the list of approved independent review organizations compiled and maintained by the Director to conduct the expedited review. In such cases, the following provisions shall apply:
(1) The assignment of an approved independent review
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| organization to conduct an external review in accordance with this Section shall be made from those approved independent review organizations qualified to conduct external review as required by Sections 50 and 55 of this Act.
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(2) The Director shall immediately notify the health
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| carrier of the name of the assigned independent review organization. Immediately upon receipt from the Director of the name of the independent review organization assigned to conduct the external review, but in no case more than 24 hours after receiving such notice, the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method.
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(3) If the health carrier or its utilization review
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| organization fails to provide the documents and information within the specified timeframe, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination.
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(4) Within one business day after making the decision
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| to terminate the external review and make a decision to reverse the adverse determination or final adverse determination under item (3) of this subsection (c), the independent review organization shall notify the Director, the health carrier, the covered person, and, if applicable, the covered person's authorized representative of its decision to reverse the adverse determination or final adverse determination.
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(d) In addition to the documents and information provided by the health carrier or its utilization review organization and any documents and information provided by the covered person and the covered person's authorized representative, the independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider information as required by subsection (i) of Section 35 of this Act in reaching a decision.
(d-5) For expedited external reviews involving mental, emotional, nervous, or substance use disorders or conditions, the independent review organization shall consider documents and information and shall make a decision to uphold or reverse the adverse determination or final adverse determination pursuant to subsection (i-5) of Section 35.
(e) As expeditiously as the covered person's medical condition or circumstances requires, but in no event more than 72 hours after the date of receipt of the request for an expedited external review, the assigned independent review organization shall:
(1) make a decision to uphold or reverse the final
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| adverse determination; and
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(2) notify the Director, the health carrier, the
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| covered person, the covered person's health care provider, and, if applicable, the covered person's authorized representative, of the decision.
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(f) In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier's utilization review process or the health carrier's internal appeal process.
(g) Upon receipt of notice of a decision reversing the adverse determination or final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination.
(h) If the notice provided pursuant to subsection (e) of this Section was not in writing, then within 48 hours after the date of providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the Director, the health carrier, the covered person, and, if applicable, the covered person's authorized representative including the information set forth in subsection (j) of Section 35 of this Act as applicable.
(i) An expedited external review may not be provided for retrospective adverse or final adverse determinations.
(j) The assignment by the Director of an approved independent review organization to conduct an external review in accordance with this Section shall be done on a random basis among those independent review organizations approved by the Director pursuant to this Act.
(Source: P.A. 102-579, eff. 1-1-22.)
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