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92_HB1389
LRB9203582JSpc
1 AN ACT in relation to insurance.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Health Maintenance Organization Act is
5 amended by changing Section 4-10 as follows:
6 (215 ILCS 125/4-10) (from Ch. 111 1/2, par. 1409.3)
7 Sec. 4-10. (a) Medical necessity; dispute
8 resolution-independent second opinion. A Each Health
9 Maintenance Organization shall provide a mechanism for the
10 timely review by a physician holding the same class of
11 license as the primary care physician, who is unaffiliated
12 with the Health Maintenance Organization, jointly selected by
13 the patient (or the patient's next of kin or legal
14 representative if the patient is unable to act for himself),
15 primary care physician and the Health Maintenance
16 Organization in the event of a dispute between the primary
17 care physician and the Health Maintenance Organization
18 regarding the medical necessity of a covered service proposed
19 by a primary care physician. In the event that the reviewing
20 physician determines the covered service to be medically
21 necessary, the Health Maintenance Organization shall provide
22 the covered service. Future contractual or employment action
23 by the Health Maintenance Organization regarding the primary
24 care physician shall not be based solely on the physician's
25 participation in this procedure.
26 (Source: P.A. 85-20; 85-850.)