97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB0224

 

Introduced 01/21/11, by Rep. Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 180/35

    Amends the Health Carrier External Review Act in the provision concerning standard external review. Provides that whenever a request is eligible for external review (1) the health carrier shall, within 2 (instead of 5) business days, request the Director of Insurance to assign an independent review organization (now, from the list of approved independent review organizations compiled and maintained by the Director) and (2) within 3 business days after receiving the health carrier's request, the Director shall assign, on a rotating basis, an independent review organization from the list of approved independent review organizations compiled and maintained by the Director. Includes the health carrier among those to be notified in writing by the Director of the request's eligibility and acceptance for external review. Effective immediately.


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A BILL FOR

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Health Carrier External Review Act is
5amended by changing Section 35 as follows:
 
6    (215 ILCS 180/35)
7    Sec. 35. Standard external review.
8    (a) Within 4 months after the date of receipt of a notice
9of an adverse determination or final adverse determination, a
10covered person or the covered person's authorized
11representative may file a request for an external review with
12the health carrier.
13    (b) Within 5 business days following the date of receipt of
14the external review request, the health carrier shall complete
15a preliminary review of the request to determine whether:
16        (1) the individual is or was a covered person in the
17    health benefit plan at the time the health care service was
18    requested or at the time the health care service was
19    provided;
20        (2) the health care service that is the subject of the
21    adverse determination or the final adverse determination
22    is a covered service under the covered person's health
23    benefit plan, but the health carrier has determined that

 

 

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1    the health care service is not covered because it does not
2    meet the health carrier's requirements for medical
3    necessity, appropriateness, health care setting, level of
4    care, or effectiveness;
5        (3) the covered person has exhausted the health
6    carrier's internal grievance process as set forth in this
7    Act;
8        (4) for appeals relating to a determination based on
9    treatment being experimental or investigational, the
10    requested health care service or treatment that is the
11    subject of the adverse determination or final adverse
12    determination is a covered benefit under the covered
13    person's health benefit plan except for the health
14    carrier's determination that the service or treatment is
15    experimental or investigational for a particular medical
16    condition and is not explicitly listed as an excluded
17    benefit under the covered person's health benefit plan with
18    the health carrier and that the covered person's health
19    care provider, who ordered or provided the services in
20    question and who is licensed under the Medical Practice Act
21    of 1987, has certified that one of the following situations
22    is applicable:
23            (A) standard health care services or treatments
24        have not been effective in improving the condition of
25        the covered person;
26            (B) standard health care services or treatments

 

 

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1        are not medically appropriate for the covered person;
2            (C) there is no available standard health care
3        service or treatment covered by the health carrier that
4        is more beneficial than the recommended or requested
5        health care service or treatment;
6            (D) the health care service or treatment is likely
7        to be more beneficial to the covered person, in the
8        health care provider's opinion, than any available
9        standard health care services or treatments; or
10            (E) that scientifically valid studies using
11        accepted protocols demonstrate that the health care
12        service or treatment requested is likely to be more
13        beneficial to the covered person than any available
14        standard health care services or treatments; and
15        (5) the covered person has provided all the information
16    and forms required to process an external review, as
17    specified in this Act.
18    (c) Within one business day after completion of the
19preliminary review, the health carrier shall notify the covered
20person and, if applicable, the covered person's authorized
21representative in writing whether the request is complete and
22eligible for external review. If the request:
23        (1) is not complete, the health carrier shall inform
24    the covered person and, if applicable, the covered person's
25    authorized representative in writing and include in the
26    notice what information or materials are required by this

 

 

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1    Act to make the request complete; or
2        (2) is not eligible for external review, the health
3    carrier shall inform the covered person and, if applicable,
4    the covered person's authorized representative in writing
5    and include in the notice the reasons for its
6    ineligibility.
7    The notice of initial determination of ineligibility shall
8include a statement informing the covered person and, if
9applicable, the covered person's authorized representative
10that a health carrier's initial determination that the external
11review request is ineligible for review may be appealed to the
12Director by filing a complaint with the Director.
13    Notwithstanding a health carrier's initial determination
14that the request is ineligible for external review, the
15Director may determine that a request is eligible for external
16review and require that it be referred for external review. In
17making such determination, the Director's decision shall be in
18accordance with the terms of the covered person's health
19benefit plan and shall be subject to all applicable provisions
20of this Act.
21    (d) Whenever a request is eligible for external review:
22        (1) the health carrier shall, within 2 5 business days,
23    request the Director to : (1) assign an independent review
24    organization from the list of approved independent review
25    organizations compiled and maintained by the Director; and
26        (2) within 3 business days after receiving the health

 

 

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1    carrier's request, the Director shall assign, on a rotating
2    basis, an independent review organization from the list of
3    approved independent review organizations compiled and
4    maintained by the Director and notify in writing the health
5    carrier, covered person, and, if applicable, the covered
6    person's authorized representative of the request's
7    eligibility and acceptance for external review and the name
8    of the independent review organization.
9    The health carrier shall include in the notice provided to
10the covered person and, if applicable, the covered person's
11authorized representative a statement that the covered person
12or the covered person's authorized representative may, within 5
13business days following the date of receipt of the notice
14provided pursuant to item (2) of this subsection (d), submit in
15writing to the assigned independent review organization
16additional information that the independent review
17organization shall consider when conducting the external
18review. The independent review organization is not required to,
19but may, accept and consider additional information submitted
20after 5 business days.
21    (e) The assignment of an approved independent review
22organization to conduct an external review in accordance with
23this Section shall be made from those approved independent
24review organizations qualified to conduct external review as
25required by Sections 50 and 55 of this Act.
26    (f) Upon assignment of an independent review organization,

 

 

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1the health carrier or its designee utilization review
2organization shall, within 5 business days, provide to the
3assigned independent review organization the documents and any
4information considered in making the adverse determination or
5final adverse determination; in such cases, the following
6provisions shall apply:
7        (1) Except as provided in item (2) of this subsection
8    (f), failure by the health carrier or its utilization
9    review organization to provide the documents and
10    information within the specified time frame shall not delay
11    the conduct of the external review.
12        (2) If the health carrier or its utilization review
13    organization fails to provide the documents and
14    information within the specified time frame, the assigned
15    independent review organization may terminate the external
16    review and make a decision to reverse the adverse
17    determination or final adverse determination.
18        (3) Within one business day after making the decision
19    to terminate the external review and make a decision to
20    reverse the adverse determination or final adverse
21    determination under item (2) of this subsection (f), the
22    independent review organization shall notify the health
23    carrier, the covered person and, if applicable, the covered
24    person's authorized representative, of its decision to
25    reverse the adverse determination.
26    (g) Upon receipt of the information from the health carrier

 

 

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1or its utilization review organization, the assigned
2independent review organization shall review all of the
3information and documents and any other information submitted
4in writing to the independent review organization by the
5covered person and the covered person's authorized
6representative.
7    (h) Upon receipt of any information submitted by the
8covered person or the covered person's authorized
9representative, the independent review organization shall
10forward the information to the health carrier within 1 business
11day.
12        (1) Upon receipt of the information, if any, the health
13    carrier may reconsider its adverse determination or final
14    adverse determination that is the subject of the external
15    review.
16        (2) Reconsideration by the health carrier of its
17    adverse determination or final adverse determination shall
18    not delay or terminate the external review.
19        (3) The external review may only be terminated if the
20    health carrier decides, upon completion of its
21    reconsideration, to reverse its adverse determination or
22    final adverse determination and provide coverage or
23    payment for the health care service that is the subject of
24    the adverse determination or final adverse determination.
25    In such cases, the following provisions shall apply:
26            (A) Within one business day after making the

 

 

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1        decision to reverse its adverse determination or final
2        adverse determination, the health carrier shall notify
3        the covered person and if applicable, the covered
4        person's authorized representative, and the assigned
5        independent review organization in writing of its
6        decision.
7            (B) Upon notice from the health carrier that the
8        health carrier has made a decision to reverse its
9        adverse determination or final adverse determination,
10        the assigned independent review organization shall
11        terminate the external review.
12    (i) In addition to the documents and information provided
13by the health carrier or its utilization review organization
14and the covered person and the covered person's authorized
15representative, if any, the independent review organization,
16to the extent the information or documents are available and
17the independent review organization considers them
18appropriate, shall consider the following in reaching a
19decision:
20        (1) the covered person's pertinent medical records;
21        (2) the covered person's health care provider's
22    recommendation;
23        (3) consulting reports from appropriate health care
24    providers and other documents submitted by the health
25    carrier, the covered person, the covered person's
26    authorized representative, or the covered person's

 

 

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1    treating provider;
2        (4) the terms of coverage under the covered person's
3    health benefit plan with the health carrier to ensure that
4    the independent review organization's decision is not
5    contrary to the terms of coverage under the covered
6    person's health benefit plan with the health carrier;
7        (5) the most appropriate practice guidelines, which
8    shall include applicable evidence-based standards and may
9    include any other practice guidelines developed by the
10    federal government, national or professional medical
11    societies, boards, and associations;
12        (6) any applicable clinical review criteria developed
13    and used by the health carrier or its designee utilization
14    review organization; and
15        (7) the opinion of the independent review
16    organization's clinical reviewer or reviewers after
17    considering items (1) through (6) of this subsection (i) to
18    the extent the information or documents are available and
19    the clinical reviewer or reviewers considers the
20    information or documents appropriate; and
21        (8) for a denial of coverage based on a determination
22    that the health care service or treatment recommended or
23    requested is experimental or investigational, whether and
24    to what extent:
25            (A) the recommended or requested health care
26        service or treatment has been approved by the federal

 

 

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1        Food and Drug Administration, if applicable, for the
2        condition;
3            (B) medical or scientific evidence or
4        evidence-based standards demonstrate that the expected
5        benefits of the recommended or requested health care
6        service or treatment is more likely than not to be
7        beneficial to the covered person than any available
8        standard health care service or treatment and the
9        adverse risks of the recommended or requested health
10        care service or treatment would not be substantially
11        increased over those of available standard health care
12        services or treatments; or
13            (C) the terms of coverage under the covered
14        person's health benefit plan with the health carrier to
15        ensure that the health care service or treatment that
16        is the subject of the opinion is experimental or
17        investigational would otherwise be covered under the
18        terms of coverage of the covered person's health
19        benefit plan with the health carrier.
20    (j) Within 5 days after the date of receipt of all
21necessary information, the assigned independent review
22organization shall provide written notice of its decision to
23uphold or reverse the adverse determination or the final
24adverse determination to the health carrier, the covered person
25and, if applicable, the covered person's authorized
26representative. In reaching a decision, the assigned

 

 

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1independent review organization is not bound by any claim
2determinations reached prior to the submission of information
3to the independent review organization. In such cases, the
4following provisions shall apply:
5        (1) The independent review organization shall include
6    in the notice:
7            (A) a general description of the reason for the
8        request for external review;
9            (B) the date the independent review organization
10        received the assignment from the health carrier to
11        conduct the external review;
12            (C) the time period during which the external
13        review was conducted;
14            (D) references to the evidence or documentation,
15        including the evidence-based standards, considered in
16        reaching its decision;
17            (E) the date of its decision; and
18            (F) the principal reason or reasons for its
19        decision, including what applicable, if any,
20        evidence-based standards that were a basis for its
21        decision.
22        (2) For reviews of experimental or investigational
23    treatments, the notice shall include the following
24    information:
25            (A) a description of the covered person's medical
26        condition;

 

 

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1            (B) a description of the indicators relevant to
2        whether there is sufficient evidence to demonstrate
3        that the recommended or requested health care service
4        or treatment is more likely than not to be more
5        beneficial to the covered person than any available
6        standard health care services or treatments and the
7        adverse risks of the recommended or requested health
8        care service or treatment would not be substantially
9        increased over those of available standard health care
10        services or treatments;
11            (C) a description and analysis of any medical or
12        scientific evidence considered in reaching the
13        opinion;
14            (D) a description and analysis of any
15        evidence-based standards;
16            (E) whether the recommended or requested health
17        care service or treatment has been approved by the
18        federal Food and Drug Administration, for the
19        condition;
20            (F) whether medical or scientific evidence or
21        evidence-based standards demonstrate that the expected
22        benefits of the recommended or requested health care
23        service or treatment is more likely than not to be more
24        beneficial to the covered person than any available
25        standard health care service or treatment and the
26        adverse risks of the recommended or requested health

 

 

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1        care service or treatment would not be substantially
2        increased over those of available standard health care
3        services or treatments; and
4            (G) the written opinion of the clinical reviewer,
5        including the reviewer's recommendation as to whether
6        the recommended or requested health care service or
7        treatment should be covered and the rationale for the
8        reviewer's recommendation.
9        (3) In reaching a decision, the assigned independent
10    review organization is not bound by any decisions or
11    conclusions reached during the health carrier's
12    utilization review process or the health carrier's
13    internal grievance or appeals process.
14        (4) Upon receipt of a notice of a decision reversing
15    the adverse determination or final adverse determination,
16    the health carrier immediately shall approve the coverage
17    that was the subject of the adverse determination or final
18    adverse determination.
19(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)
 
20    Section 99. Effective date. This Act takes effect upon
21becoming law.