TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4530 HEALTH CARRIER EXTERNAL REVIEW
SECTION 4530.30 DEFINITIONS
Section 4530.30 Definitions
"Act" means the Health Carrier External Review Act [215 ILCS 180].
"Adverse Determination" means:
A determination by a health carrier or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health carrier's health benefit plan, upon application of any utilization review technique, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational, and the requested benefit is therefore denied, reduced or terminated, or payment is not provided or made, in whole or part, for the benefit;
The denial, reduction or termination of, or failure to provide or make payment, in whole or in part, for, a benefit based on a determination by a health carrier or its designee utilization review organization that a preexisting condition was present before the effective date of coverage; or
A rescission of coverage determination, which does not include a cancellation or discontinuance of coverage that is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.
"Authorized Representative" means:
A person to whom a covered person has given express written consent to represent the covered person for purposes of the Act;
A person authorized by law to provide substituted consent for a covered person;
A family member of the covered person or the covered person's treating health care professional when the covered person is unable to provide consent;
A health care provider when the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the health care provider; or
In the case of an urgent care request, a health care provider with knowledge of the covered person's medical condition.
"Best Evidence" means evidence based on:
Randomized clinical trials;
If randomized clinical trials are not available, then cohort studies or case-control studies;
If the prior two items are not available, then case-series; or
If the prior three items are not available, then expert opinion.
"Case-control Study" means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.
"Case-series" means an evaluation of a series of patients with a particular outcome, without the use of a control group.
"Clinical Review Criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.
"Cohort Study" means a prospective evaluation of 2 groups of patients with only one group of patients receiving specific intervention.
"Code" means the Illinois Insurance Code [215 ILCS 5].
"Concurrent Review" means a review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional, or other inpatient or outpatient health care setting.
"Covered Benefits" or "Benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.
"Covered Person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
"Director" means the Director of the Illinois Department of Insurance.
"Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
serious impairment to bodily functions; or
serious dysfunction of any bodily organ or part.
"Evidence-based Standard" means the conscientious, explicit and judicious use of the current best evidence based on an overall systematic review of the research in making decisions about the care of individual patients.
"Expert Opinion" means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy.
"Facility" means an institution providing health care services or a health care setting.
"Final Adverse Determination" means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth by the Managed Care Reform and Patient Rights Act [215 ILCS 134].
"Health Benefit Plan" means a policy, contract, certificate, plan, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
"Health Care Provider" or "Provider" means a physician, hospital facility, or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with State law, responsible for recommending health care services on behalf of a covered person.
"Health Care Services" means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.
"Health Carrier" means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, or any other entity providing a plan of health insurance, health benefits, or health care services. "Health carrier" also means Limited Health Service Organizations (LHSO) and Voluntary Health Service Plans.
"Health Information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to:
The past, present, or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family;
The provision of health care services to an individual; or
Payment for the provision of health care services to an individual.
"Independent Review Organization" or "IRO" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.
"Medical Necessity" means health care services and supplies provided by a health care provider, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care, including the evaluation of experimental and/or investigational services, procedures, drugs or devices.
"Medical or Scientific Evidence" means evidence found in the following sources:
Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;
Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meets the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE);
Medical journals recognized by the Secretary of Health and Human Services under section 1861(t)(2) of the federal Social Security Act (42 USC 1861(t)(2));
The following standard reference compendia:
The American Hospital Formulary Service Drug Information;
Drug Facts and Comparisons;
The American Dental Association Accepted Dental Therapeutics; and
The United States Pharmacopoeia Drug Information;
Findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:
The federal Agency for Healthcare Research and Quality;
The National Institutes of Health;
The National Cancer Institute;
The National Academy of Sciences;
The Centers for Medicare & Medicaid Services;
The federal Food and Drug Administration; and
Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or
Any other medical or scientific evidence that is comparable to the sources listed in this definition.
Medical necessity determinations for substance use disorders shall be made in accordance with appropriate patient placement criteria established by the American Society of Addiction Medicine [215 ILCS 5/370c(b)(3)].
"Member" means a covered person as defined by this Part.
"Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing.
"Prospective Review" means a review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health carrier's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision.
"Protected Health Information" means health information that identifies an individual who is the subject of the information, or with respect to which there is a reasonable basis to believe that the information could be used to identify an individual.
"Randomized Clinical Trial" means a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time.
"Retrospective Review" means any review of a request for a benefit that is not a concurrent or prospective review request. "Retrospective Review" does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.
"Utilization Review" means the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities.
"Utilization Review Organization" means a utilization review program as defined in the Managed Care Reform and Patient Rights Act.
(Source: Amended at 39 Ill. Reg. 4077, effective September 1, 2015)