Illinois General Assembly

  Bills & Resolutions  
  Compiled Statutes  
  Public Acts  
  Legislative Reports  
  IL Constitution  
  Legislative Guide  
  Legislative Glossary  

 Search By Number
 (example: HB0001)
Search Tips

Search By Keyword

Illinois Compiled Statutes

 ILCS Listing   Public Acts  Search   Guide   Disclaimer

Information maintained by the Legislative Reference Bureau
Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process. Recent laws may not yet be included in the ILCS database, but they are found on this site as Public Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the Guide.

Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If the source note at the end of a Section of the statutes includes a Public Act that has not yet taken effect, the version of the law that is currently in effect may have already been removed from the database and you should refer to that Public Act to see the changes made to the current law.

215 ILCS 200/20

    (215 ILCS 200/20)
    Sec. 20. Disclosure and review of prior authorization requirements.
    (a) A health insurance issuer shall maintain a complete list of services for which prior authorization is required, including for all services where prior authorization is performed by an entity under contract with the health insurance issuer.
    (b) A health insurance issuer shall make any current prior authorization requirements and restrictions, including the written clinical review criteria, readily accessible and conspicuously posted on its website to enrollees, health care professionals, and health care providers. Content published by a third party and licensed for use by a health insurance issuer or its contracted utilization review organization may be made available through the health insurance issuer's or its contracted utilization review organization's secure, password-protected website so long as the access requirements of the website do not unreasonably restrict access. Requirements shall be described in detail, written in easily understandable language, and readily available to the health care professional and health care provider at the point of care. The website shall indicate for each service subject to prior authorization:
        (1) when prior authorization became required for
policies issued or delivered in Illinois, including the effective date or dates and the termination date or dates, if applicable, in Illinois;
        (2) the date the Illinois-specific requirement
was listed on the health insurance issuer's or its contracted utilization review organization's website;
        (3) where applicable, the date that prior
authorization was removed for Illinois; and
        (4) where applicable, access to a standardized
electronic prior authorization request transaction process.
    (c) The clinical review criteria must:
        (1) be based on nationally recognized, generally
accepted standards except where State law provides its own standard;
        (2) be developed in accordance with the current
standards of a national medical accreditation entity;
        (3) ensure quality of care and access to needed
health care services;
        (4) be evidence-based;
        (5) be sufficiently flexible to allow deviations
from norms when justified on a case-by-case basis; and
        (6) be evaluated and updated, if necessary, at
least annually.
    (d) A health insurance issuer shall not deny a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date of service on the claim.
    (e) A health insurance issuer or its contracted utilization review organization shall not deem as incidental or deny supplies or health care services that are routinely used as part of a health care service when:
        (1) an associated health care service has received
prior authorization; or
        (2) prior authorization for the health care service
is not required.
    (f) If a health insurance issuer intends either to implement a new prior authorization requirement or restriction or amend an existing requirement or restriction, the health insurance issuer shall provide contracted health care professionals and contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented. The written notice may be provided in an electronic format, including email or facsimile, if the health care professional or health care provider has agreed in advance to receive notices electronically. The health insurance issuer shall ensure that the new or amended requirement is not implemented unless the health insurance issuer's or its contracted utilization review organization's website has been updated to reflect the new or amended requirement or restriction.
    (g) Entities using prior authorization shall make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. The statistics must be updated annually and include all of the following information:
        (1) a list of all health care services, including
medications, that are subject to prior authorization;
        (2) the total number of prior authorization
requests received;
        (3) the number of prior authorization requests
denied during the previous plan year by the health insurance issuer or its contracted utilization review organization with respect to each service described in paragraph (1) and the top 5 reasons for denial;
        (4) the number of requests described in paragraph
(3) that were appealed, the number of the appealed requests that upheld the adverse determination, and the number of appealed requests that reversed the adverse determination;
        (5) the average time between submission and
response; and
        (6) any other information as the Director
determines appropriate.
(Source: P.A. 102-409, eff. 1-1-22.)