(215 ILCS 134/10)
"Adverse determination" means a determination by a health care plan under
Section 45 or by a utilization review program under Section
a health care service is not medically necessary.
"Clinical peer" means a health care professional who is in the same
profession and the same or similar specialty as the health care provider who
typically manages the medical condition, procedures, or treatment under
"Department" means the 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:
(1) 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;
impairment to bodily functions; or
(3) serious dysfunction of any bodily organ
"Emergency medical screening examination" means a medical screening
evaluation by a physician licensed to practice medicine in all its branches, or
to the extent permitted
by applicable laws, by other appropriately licensed personnel under the
supervision of or in
collaboration with a physician licensed to practice medicine in all its
branches to determine whether
the need for emergency services exists.
"Emergency services" means, with respect to an enrollee of a health care
transportation services, including but not limited to ambulance services, and
covered inpatient and outpatient hospital services
furnished by a provider
qualified to furnish those services that are needed to evaluate or stabilize an
emergency medical condition. "Emergency services" does not
refer to post-stabilization medical services.
"Enrollee" means any person and his or her dependents enrolled in or covered
by a health care plan.
"Health care plan" means a plan, including, but not limited to, a health maintenance organization, a managed care community network as defined in the Illinois Public Aid Code, or an accountable care entity as defined in the Illinois Public Aid Code that receives capitated payments to cover medical services from the Department of Healthcare and Family Services, that establishes, operates, or maintains a
network of health care providers that has entered into an agreement with the
plan to provide health care services to enrollees to whom the plan has the
ultimate obligation to arrange for the provision of or payment for services
through organizational arrangements for ongoing quality assurance,
utilization review programs, or dispute resolution.
Nothing in this definition shall be construed to mean that an independent
practice association or a physician hospital organization that subcontracts
a health care plan is, for purposes of that subcontract, a health care plan.
For purposes of this definition, "health care plan" shall not include the
(1) indemnity health insurance policies including
those using a contracted provider network;
(2) health care plans that offer only dental or only
(3) preferred provider administrators, as defined in
Section 370g(g) of the Illinois Insurance Code;
(4) employee or employer self-insured health benefit
plans under the federal Employee Retirement Income Security Act of 1974;
(5) health care provided pursuant to the Workers'
Compensation Act or the Workers' Occupational Diseases Act; and
(6) not-for-profit voluntary health services plans
with health maintenance organization authority in existence as of January 1, 1999 that are affiliated with a union and that only extend coverage to union members and their dependents.
"Health care professional" means a physician, a registered professional
or other individual appropriately licensed or registered
to provide health care services.
"Health care provider" means any physician, hospital facility, facility licensed under the Nursing Home Care Act, long-term care facility as defined in Section 1-113 of the Nursing Home Care Act, or other
person that is licensed or otherwise authorized to deliver health care
services. Nothing in this
Act shall be construed to define Independent Practice Associations or
Physician-Hospital Organizations as health care providers.
"Health care services" means any services included in the furnishing to any
individual of medical care, or the
hospitalization incident to the furnishing of such care, as well as the
furnishing to any person of
any and all other services for the purpose of preventing,
alleviating, curing, or healing human illness or injury including home health
and pharmaceutical services and products.
"Medical director" means a physician licensed in any state to practice
medicine in all its
branches appointed by a health care plan.
"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other legal entity.
"Physician" means a person licensed under the Medical
Practice Act of 1987.
"Post-stabilization medical services" means health care services
provided to an enrollee that are furnished in a licensed hospital by a provider
that is qualified to furnish such services, and determined to be medically
necessary and directly related to the emergency medical condition following
"Stabilization" means, with respect to an emergency medical condition, to
provide such medical treatment of the condition as may be necessary to assure,
within reasonable medical probability, that no material deterioration
of the condition is likely to result.
"Utilization review" means the evaluation of the medical necessity,
appropriateness, and efficiency of the use of health care services, procedures,
"Utilization review program" means a program established by a person to
perform utilization review.
(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78, eff. 7-20-15.)