Illinois General Assembly - Full Text of Public Act 099-0537
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Public Act 099-0537


 

Public Act 0537 99TH GENERAL ASSEMBLY

  
  
  

 


 
Public Act 099-0537
 
SB2787 EnrolledLRB099 16154 MLM 40480 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Health Carrier External Review Act is
amended by changing Section 65 as follows:
 
    (215 ILCS 180/65)
    Sec. 65. External review reporting requirements.
    (a) Each health carrier shall maintain written records in
the aggregate, by state, and for each type of health benefit
plan offered by the health carrier on all requests for external
review that the health carrier received notice from the
Director for each calendar year and submit a report to the
Director in the format specified by the Director by June 1
March 1 of each year.
    (a-5) An independent review organization assigned pursuant
to this Act to conduct an external review shall maintain
written records in the aggregate by state and by health carrier
on all requests for external review for which it conducted an
external review during a calendar year and submit a report in
the format specified by the Director by March 1 of each year.
    (a-10) The report required by subsection (a-5) shall
include in the aggregate by state, and for each health carrier:
        (1) the total number of requests for external review;
        (2) the number of requests for external review resolved
    and, of those resolved, the number resolved upholding the
    adverse determination or final adverse determination and
    the number resolved reversing the adverse determination or
    final adverse determination;
        (3) the average length of time for resolution;
        (4) a summary of the types of coverages or cases for
    which an external review was sought, as provided in the
    format required by the Director;
        (5) the number of external reviews that were terminated
    as the result of a reconsideration by the health carrier of
    its adverse determination or final adverse determination
    after the receipt of additional information from the
    covered person or the covered person's authorized
    representative; and
        (6) any other information the Director may request or
    require.
    (a-15) The independent review organization shall retain
the written records required pursuant to this Section for at
least 3 years.
    (b) The report required under subsection (a) of this
Section shall include in the aggregate, by state, and by type
of health benefit plan:
        (1) the total number of requests for external review;
        (2) the total number of requests for expedited external
    review;
        (3) the total number of requests for external review
    denied;
        (4) the number of requests for external review
    resolved, including:
            (A) the number of requests for external review
        resolved upholding the adverse determination or final
        adverse determination;
            (B) the number of requests for external review
        resolved reversing the adverse determination or final
        adverse determination;
            (C) the number of requests for expedited external
        review resolved upholding the adverse determination or
        final adverse determination; and
            (D) the number of requests for expedited external
        review resolved reversing the adverse determination or
        final adverse determination;
        (5) the average length of time for resolution for an
    external review;
        (6) the average length of time for resolution for an
    expedited external review;
        (7) a summary of the types of coverages or cases for
    which an external review was sought, as specified below:
            (A) denial of care or treatment (dissatisfaction
        regarding prospective non-authorization of a request
        for care or treatment recommended by a provider
        excluding diagnostic procedures and referral requests;
        partial approvals and care terminations are also
        considered to be denials);
            (B) denial of diagnostic procedure
        (dissatisfaction regarding prospective
        non-authorization of a request for a diagnostic
        procedure recommended by a provider; partial approvals
        are also considered to be denials);
            (C) denial of referral request (dissatisfaction
        regarding non-authorization of a request for a
        referral to another provider recommended by a PCP);
            (D) claims and utilization review (dissatisfaction
        regarding the concurrent or retrospective evaluation
        of the coverage, medical necessity, efficiency or
        appropriateness of health care services or treatment
        plans; prospective "Denials of care or treatment",
        "Denials of diagnostic procedures" and "Denials of
        referral requests" should not be classified in this
        category, but the appropriate one above);
        (8) the number of external reviews that were terminated
    as the result of a reconsideration by the health carrier of
    its adverse determination or final adverse determination
    after the receipt of additional information from the
    covered person or the covered person's authorized
    representative; and
        (9) any other information the Director may request or
    require.
(Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.)
 
    Section 99. Effective date. This Act takes effect January
1, 2017.

Effective Date: 1/1/2017