(820 ILCS 305/8.7)
    Sec. 8.7. Utilization review programs.
    (a) As used in this Section:
    "Utilization review" means the evaluation of proposed or provided health care services to determine the appropriateness of both the level of health care services medically necessary and the quality of health care services provided to a patient, including evaluation of their efficiency, efficacy, and appropriateness of treatment, hospitalization, or office visits based on medically accepted standards. The evaluation must be accomplished by means of a system that identifies the utilization of health care services based on standards of care or nationally recognized peer review guidelines as well as nationally recognized evidence based upon standards as provided in this Act. Utilization techniques may include prospective review, second opinions, concurrent review, discharge planning, peer review, independent medical examinations, and retrospective review (for purposes of this sentence, retrospective review shall be applicable to services rendered on or after July 20, 2005). Nothing in this Section applies to prospective review of necessary first aid or emergency treatment.
    (b) No person may conduct a utilization review program for workers' compensation services in this State unless once every 2 years the person registers the utilization review program with the Department of Financial and Professional Regulation and certifies compliance with the Workers' Compensation Utilization Management standards or Health Utilization Management Standards of URAC sufficient to achieve URAC accreditation or submits evidence of accreditation by URAC for its Workers' Compensation Utilization Management Standards or Health Utilization Management Standards. Nothing in this Act shall be construed to require an employer or insurer or its subcontractors to become URAC accredited.
    (c) In addition, the Secretary of Financial and Professional Regulation 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 (b).
    (d) This registration shall include submission of all of the following information 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
    
program.
        (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) A utilization review program shall have written
    
procedures to ensure that patient‑specific information obtained during the process of utilization review will be:
        (1) kept confidential in accordance with applicable
    
State and federal laws; and
        (2) shared only with the employee, the employee's
    
designee, and the employee'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 providers.
    Only a health care professional may make determinations
    
regarding the medical necessity of health care services during the course of utilization review.
    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.
    (f) If the Department of Financial and Professional
    
Regulation 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 the 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) The Secretary of Financial and Professional
    
Regulation may by rule establish a registration fee for each person conducting a utilization review program.
    (i) A utilization review will be considered by the
    
Commission, along with all other evidence and in the same manner as all other evidence, in the determination of the reasonableness and necessity of the medical bills or treatment. Nothing in this Section shall be construed to diminish the rights of employees to reasonable and necessary medical treatment or employee choice of health care provider under Section 8(a) or the rights of employers to medical examinations under Section 12.
    (j) When an employer denies payment of or refuses to
    
authorize payment of first aid, medical, surgical, or hospital services under Section 8(a) of this Act, if that denial or refusal to authorize complies with a utilization review program registered under this Section and complies with all other requirements of this Section, then there shall be a rebuttable presumption that the employer shall not be responsible for payment of additional compensation pursuant to Section 19(k) of this Act and if that denial or refusal to authorize does not comply with a utilization review program registered under this Section and does not comply with all other requirements of this Section, then that will be considered by the Commission, along with all other evidence and in the same manner as all other evidence, in the determination of whether the employer may be responsible for the payment of additional compensation pursuant to Section 19(k) of this Act.
(Source: P.A. 94‑277, eff. 7‑20‑05; 94‑695, eff. 11‑16‑05.)