Sen. Heather A. Steans

Filed: 5/10/2011

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 224

2    AMENDMENT NO. ______. Amend House Bill 224 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Health Carrier External Review Act is
5amended by changing Sections 10, 20, 25, 30, 35, 40, 55, 65,
6and 75 and by adding Sections 42 and 80 as follows:
 
7    (215 ILCS 180/10)
8    Sec. 10. Definitions. For the purposes of this Act:
9    "Adverse determination" means:
10        (1) a determination by a health carrier or its designee
11    utilization review organization that, based upon the
12    information provided, a request for a benefit under the
13    health carrier's health benefit plan upon application of
14    any utilization review technique does not meet the health
15    carrier's requirements for medical necessity,
16    appropriateness, health care setting, level of care, or

 

 

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1    effectiveness or is determined to be experimental or
2    investigational and the requested benefit is therefore
3    denied, reduced, or terminated or payment is not provided
4    or made, in whole or in part, for the benefit;
5        (2) the denial, reduction, or termination of or failure
6    to provide or make payment, in whole or in part, for a
7    benefit based on a determination by a health carrier or its
8    designee utilization review organization of a covered
9    person's eligibility to participate in the health
10    carrier's health benefit plan;
11        (3) any prospective review or retrospective review
12    determination that denies, reduces, or terminates or fails
13    to provide or make payment, in whole or in part, for a
14    benefit; or
15        (4) a rescission of coverage determination. means a
16    determination by a health carrier or its designee
17    utilization review organization that an admission,
18    availability of care, continued stay, or other health care
19    service that is a covered benefit has been reviewed and,
20    based upon the information provided, does not meet the
21    health carrier's requirements for medical necessity,
22    appropriateness, health care setting, level of care, or
23    effectiveness, and the requested service or payment for the
24    service is therefore denied, reduced, or terminated.
25    "Authorized representative" means:
26        (1) a person to whom a covered person has given express

 

 

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1    written consent to represent the covered person for
2    purposes of this Law;
3        (2) a person authorized by law to provide substituted
4    consent for a covered person;
5        (3) a family member of the covered person or the
6    covered person's treating health care professional when
7    the covered person is unable to provide consent;
8        (4) a health care provider when the covered person's
9    health benefit plan requires that a request for a benefit
10    under the plan be initiated by the health care provider; or
11        (5) in the case of an urgent care request, a health
12    care provider with knowledge of the covered person's
13    medical condition.
14        (1) a person to whom a covered person has given express
15    written consent to represent the covered person in an
16    external review, including the covered person's health
17    care provider;
18        (2) a person authorized by law to provide substituted
19    consent for a covered person; or
20        (3) the covered person's health care provider when the
21    covered person is unable to provide consent.
22    "Best evidence" means evidence based on:
23        (1) randomized clinical trials;
24        (2) if randomized clinical trials are not available,
25    then cohort studies or case-control studies;
26        (3) if items (1) and (2) are not available, then

 

 

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1    case-series; or
2        (4) if items (1), (2), and (3) are not available, then
3    expert opinion.
4    "Case-series" means an evaluation of a series of patients
5with a particular outcome, without the use of a control group.
6    "Clinical review criteria" means the written screening
7procedures, decision abstracts, clinical protocols, and
8practice guidelines used by a health carrier to determine the
9necessity and appropriateness of health care services.
10    "Cohort study" means a prospective evaluation of 2 groups
11of patients with only one group of patients receiving specific
12intervention.
13    "Concurrent review" means a review conducted during a
14patient's stay or course of treatment in a facility, the office
15of a health care professional, or other inpatient or outpatient
16health care setting.
17    "Covered benefits" or "benefits" means those health care
18services to which a covered person is entitled under the terms
19of a health benefit plan.
20    "Covered person" means a policyholder, subscriber,
21enrollee, or other individual participating in a health benefit
22plan.
23    "Director" means the Director of the Department of
24Insurance.
25    "Emergency medical condition" means a medical condition
26manifesting itself by acute symptoms of sufficient severity,

 

 

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1including, but not limited to, severe pain, such that a prudent
2layperson who possesses an average knowledge of health and
3medicine could reasonably expect the absence of immediate
4medical attention to result in:
5        (1) placing the health of the individual or, with
6    respect to a pregnant woman, the health of the woman or her
7    unborn child, in serious jeopardy;
8        (2) serious impairment to bodily functions; or
9        (3) serious dysfunction of any bodily organ or part.
10    "Emergency services" means health care items and services
11furnished or required to evaluate and treat an emergency
12medical condition.
13    "Evidence-based standard" means the conscientious,
14explicit, and judicious use of the current best evidence based
15on an overall systematic review of the research in making
16decisions about the care of individual patients.
17    "Expert opinion" means a belief or an interpretation by
18specialists with experience in a specific area about the
19scientific evidence pertaining to a particular service,
20intervention, or therapy.
21    "Facility" means an institution providing health care
22services or a health care setting.
23    "Final adverse determination" means an adverse
24determination involving a covered benefit that has been upheld
25by a health carrier, or its designee utilization review
26organization, at the completion of the health carrier's

 

 

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1internal grievance process procedures as set forth by the
2Managed Care Reform and Patient Rights Act.
3    "Health benefit plan" means a policy, contract,
4certificate, plan, or agreement offered or issued by a health
5carrier to provide, deliver, arrange for, pay for, or reimburse
6any of the costs of health care services.
7    "Health care provider" or "provider" means a physician,
8hospital facility, or other health care practitioner licensed,
9accredited, or certified to perform specified health care
10services consistent with State law, responsible for
11recommending health care services on behalf of a covered
12person.
13    "Health care services" means services for the diagnosis,
14prevention, treatment, cure, or relief of a health condition,
15illness, injury, or disease.
16    "Health carrier" means an entity subject to the insurance
17laws and regulations of this State, or subject to the
18jurisdiction of the Director, that contracts or offers to
19contract to provide, deliver, arrange for, pay for, or
20reimburse any of the costs of health care services, including a
21sickness and accident insurance company, a health maintenance
22organization, or any other entity providing a plan of health
23insurance, health benefits, or health care services. "Health
24carrier" also means Limited Health Service Organizations
25(LHSO) and Voluntary Health Service Plans.
26    "Health information" means information or data, whether

 

 

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1oral or recorded in any form or medium, and personal facts or
2information about events or relationships that relate to:
3        (1) the past, present, or future physical, mental, or
4    behavioral health or condition of an individual or a member
5    of the individual's family;
6        (2) the provision of health care services to an
7    individual; or
8        (3) payment for the provision of health care services
9    to an individual.
10    "Independent review organization" means an entity that
11conducts independent external reviews of adverse
12determinations and final adverse determinations.
13    "Medical or scientific evidence" means evidence found in
14the following sources:
15        (1) peer-reviewed scientific studies published in or
16    accepted for publication by medical journals that meet
17    nationally recognized requirements for scientific
18    manuscripts and that submit most of their published
19    articles for review by experts who are not part of the
20    editorial staff;
21        (2) peer-reviewed medical literature, including
22    literature relating to therapies reviewed and approved by a
23    qualified institutional review board, biomedical
24    compendia, and other medical literature that meet the
25    criteria of the National Institutes of Health's Library of
26    Medicine for indexing in Index Medicus (Medline) and

 

 

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1    Elsevier Science Ltd. for indexing in Excerpta Medicus
2    (EMBASE);
3        (3) medical journals recognized by the Secretary of
4    Health and Human Services under Section 1861(t)(2) of the
5    federal Social Security Act;
6        (4) the following standard reference compendia:
7            (a) The American Hospital Formulary Service-Drug
8        Information;
9            (b) Drug Facts and Comparisons;
10            (c) The American Dental Association Accepted
11        Dental Therapeutics; and
12            (d) The United States Pharmacopoeia-Drug
13        Information;
14        (5) findings, studies, or research conducted by or
15    under the auspices of federal government agencies and
16    nationally recognized federal research institutes,
17    including:
18            (a) the federal Agency for Healthcare Research and
19        Quality;
20            (b) the National Institutes of Health;
21            (c) the National Cancer Institute;
22            (d) the National Academy of Sciences;
23            (e) the Centers for Medicare & Medicaid Services;
24            (f) the federal Food and Drug Administration; and
25            (g) any national board recognized by the National
26        Institutes of Health for the purpose of evaluating the

 

 

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1        medical value of health care services; or
2        (6) any other medical or scientific evidence that is
3    comparable to the sources listed in items (1) through (5).
4    "Person" means an individual, a corporation, a
5partnership, an association, a joint venture, a joint stock
6company, a trust, an unincorporated organization, any similar
7entity, or any combination of the foregoing.
8    "Prospective review" means a review conducted prior to an
9admission or the provision of a health care service or a course
10of treatment in accordance with a health carrier's requirement
11that the health care service or course of treatment, in whole
12or in part, be approved prior to its provision.
13    "Protected health information" means health information
14(i) that identifies an individual who is the subject of the
15information; or (ii) with respect to which there is a
16reasonable basis to believe that the information could be used
17to identify an individual.
18    "Randomized clinical trial" means a controlled prospective
19study of patients that have been randomized into an
20experimental group and a control group at the beginning of the
21study with only the experimental group of patients receiving a
22specific intervention, which includes study of the groups for
23variables and anticipated outcomes over time.
24    "Retrospective review" means any review of a request for a
25benefit that is not a concurrent or prospective review request.
26"Retrospective review" does not include the review of a claim

 

 

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1that is limited to veracity of documentation or accuracy of
2coding. means a review of medical necessity conducted after
3services have been provided to a patient, but does not include
4the review of a claim that is limited to an evaluation of
5reimbursement levels, veracity of documentation, accuracy of
6coding, or adjudication for payment.
7    "Utilization review" has the meaning provided by the
8Managed Care Reform and Patient Rights Act.
9    "Utilization review organization" means a utilization
10review program as defined in the Managed Care Reform and
11Patient Rights Act.
12(Source: P.A. 96-857, eff. 7-1-10.)
 
13    (215 ILCS 180/20)
14    Sec. 20. Notice of right to external review.
15    (a) At the same time the health carrier sends written
16notice of a covered person's right to appeal a coverage
17decision upon an adverse determination or a final adverse
18determination as provided by the Managed Care Reform and
19Patient Rights Act, a health carrier shall notify a covered
20person, the covered person's authorized representative, if
21any, and a covered person's health care provider in writing of
22the covered person's right to request an external review as
23provided by this Act. The written notice required shall include
24the following, or substantially equivalent, language: "We have
25denied your request for the provision of or payment for a

 

 

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1health care service or course of treatment. You have the right
2to have our decision reviewed by an independent review
3organization not associated with us if our decision involved
4making a judgment as to the medical necessity, appropriateness,
5health care setting, level of care, or effectiveness of the
6health care service or treatment you requested by submitting a
7written request for an external review to the Department of
8Insurance, Office of Consumer Health Information, 320 West
9Washington Street, 4th Floor, Springfield, Illinois, 62767."
10us. Upon receipt of your request an independent review
11organization registered with the Department of Insurance will
12be assigned to review our decision.
13    (a-5) The Department may prescribe the form and content of
14the notice required under this Section.
15    (b) This subsection (b) shall apply to an expedited review
16prior to a final adverse determination. In addition to the
17notice required in subsection (a), for the health carrier shall
18include a notice related to an adverse determination, the
19health carrier shall include a statement informing the covered
20person of all of the following:
21        (1) If the covered person has a medical condition where
22    the timeframe for completion of (A) an expedited internal
23    review of an appeal a grievance involving an adverse
24    determination, (B) a final adverse determination as set
25    forth in the Managed Care Reform and Patient Rights Act, or
26    (C) a standard external review as established in this Act,

 

 

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1    would seriously jeopardize the life or health of the
2    covered person or would jeopardize the covered person's
3    ability to regain maximum function, then the covered person
4    or the covered person's authorized representative may file
5    a request for an expedited external review.
6        (2) The covered person or the covered person's
7    authorized representative may file an appeal under the
8    health carrier's internal appeal process, but if the health
9    carrier has not issued a written decision to the covered
10    person or the covered person's authorized representative
11    30 days following the date the covered person or the
12    covered person's authorized representative files an appeal
13    of an adverse determination that involves a concurrent or
14    prospective review request or 60 days following the date
15    the covered person or the covered person's authorized
16    representative files an appeal of an adverse determination
17    that involves a retrospective review request with the
18    health carrier and the covered person or the covered
19    person's authorized representative has not requested or
20    agreed to a delay, then the covered person or the covered
21    person's authorized representative may file a request for
22    external review and shall be considered to have exhausted
23    the health carrier's internal appeal process for purposes
24    of this Act. The covered person or the covered person's
25    authorized representative may file a request for an
26    expedited external review at the same time the covered

 

 

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1    person or the covered person's authorized representative
2    files a request for an expedited internal appeal involving
3    an adverse determination as set forth in the Managed Care
4    Reform and Patient Rights Act if the adverse determination
5    involves a denial of coverage based on a determination that
6    the recommended or requested health care service or
7    treatment is experimental or investigational and the
8    covered person's health care provider certifies in writing
9    that the recommended or requested health care service or
10    treatment that is the subject of the adverse determination
11    would be significantly less effective if not promptly
12    initiated. The independent review organization assigned to
13    conduct the expedited external review will determine
14    whether the covered person shall be required to complete
15    the expedited review of the grievance prior to conducting
16    the expedited external review.
17        (3) If the covered person or the covered person's
18    authorized representative filed a request for an expedited
19    internal review of an adverse determination and has not
20    received a decision on such request from the health carrier
21    within 48 hours, except to the extent the covered person or
22    the covered person's authorized representative requested
23    or agreed to a delay, then the covered person or the
24    covered person's authorized representative may file a
25    request for external review and shall be considered to have
26    exhausted the health carrier's internal appeal process for

 

 

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1    the purposes of this Act.
2        (4) (3) If an adverse determination concerns a denial
3    of coverage based on a determination that the recommended
4    or requested health care service or treatment is
5    experimental or investigational and the covered person's
6    health care provider certifies in writing that the
7    recommended or requested health care service or treatment
8    that is the subject of the request would be significantly
9    less effective if not promptly initiated, then the covered
10    person or the covered person's authorized representative
11    may request an expedited external review at the same time
12    the covered person or the covered person's authorized
13    representative files a request for an expedited internal
14    appeal involving an adverse determination. The independent
15    review organization assigned to conduct the expedited
16    external review shall determine whether the covered person
17    is required to complete the expedited review of the appeal
18    prior to conducting the expedited external review.
19    (c) This subsection (c) shall apply to an expedited review
20upon final adverse determination. In addition to the notice
21required in subsection (a), for the health carrier shall
22include a notice related to a final adverse determination, the
23health carrier shall include a statement informing the covered
24person of all of the following:
25        (1) if the covered person has a medical condition where
26    the timeframe for completion of a standard external review

 

 

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1    would seriously jeopardize the life or health of the
2    covered person or would jeopardize the covered person's
3    ability to regain maximum function, then the covered person
4    or the covered person's authorized representative may file
5    a request for an expedited external review; or
6        (2) if a final adverse determination concerns an
7    admission, availability of care, continued stay, or health
8    care service for which the covered person received
9    emergency services, but has not been discharged from a
10    facility, then the covered person, or the covered person's
11    authorized representative, may request an expedited
12    external review; or
13        (3) if a final adverse determination concerns a denial
14    of coverage based on a determination that the recommended
15    or requested health care service or treatment is
16    experimental or investigational, and the covered person's
17    health care provider certifies in writing that the
18    recommended or requested health care service or treatment
19    that is the subject of the request would be significantly
20    less effective if not promptly initiated, then the covered
21    person or the covered person's authorized representative
22    may request an expedited external review.
23    (d) In addition to the information to be provided pursuant
24to subsections (a), (b), and (c) of this Section, the health
25carrier shall include a copy of the description of both the
26required standard and expedited external review procedures.

 

 

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1The description shall highlight the external review procedures
2that give the covered person or the covered person's authorized
3representative the opportunity to submit additional
4information, including any forms used to process an external
5review.
6    (e) As part of any forms provided under subsection (d) of
7this Section, the health carrier shall include an authorization
8form, or other document approved by the Director, by which the
9covered person, for purposes of conducting an external review
10under this Act, authorizes the health carrier and the covered
11person's treating health care provider to disclose protected
12health information, including medical records, concerning the
13covered person that is pertinent to the external review, as
14provided in the Illinois Insurance Code.
15(Source: P.A. 96-857, eff. 7-1-10.)
 
16    (215 ILCS 180/25)
17    Sec. 25. Request for external review. A covered person or
18the covered person's authorized representative may make a
19request for a standard external or expedited external review of
20an adverse determination or final adverse determination.
21Except as set forth in Sections 40 and 42 of this Act, all
22requests for external review Requests under this Section shall
23be made in writing to the Director directly to the health
24carrier that made the adverse or final adverse determination.
25All requests for external review shall be in writing except for

 

 

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1requests for expedited external reviews which may me made
2orally. Health carriers must provide covered persons with forms
3to request external reviews.
4(Source: P.A. 96-857, eff. 7-1-10.)
 
5    (215 ILCS 180/30)
6    Sec. 30. Exhaustion of internal appeal grievance process.
7    (a) Except as provided in subsection (b) of this Section
820, a request for an external review shall not be made until
9the covered person has exhausted the health carrier's internal
10appeal grievance process as set forth in the Managed Care
11Reform and Patient Rights Act.
12    (b) A covered person shall also be considered to have
13exhausted the health carrier's internal appeal grievance
14process for purposes of this Section if:
15        (1) the covered person or the covered person's
16    authorized representative has filed an appeal under the
17    health carrier's internal appeal process a request for an
18    internal review of an adverse determination pursuant to the
19    Managed Care Reform and Patient Rights Act and has not
20    received a written decision on the appeal 30 days following
21    the date the covered person or the covered person's
22    authorized representative files an appeal of an adverse
23    determination that involves a prospective review request
24    or 60 days following the date the covered person or the
25    covered person's authorized representative files an appeal

 

 

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1    of an adverse determination that involves a retrospective
2    review request request from the health carrier within 15
3    days after receipt of the required information but not more
4    than 30 days after the request was filed by the covered
5    person or the covered person's authorized representative,
6    except to the extent the covered person or the covered
7    person's authorized representative requested or agreed to
8    a delay; however, a covered person or the covered person's
9    authorized representative may not make a request for an
10    external review of an adverse determination involving a
11    retrospective review determination until the covered
12    person has exhausted the health carrier's internal
13    grievance process;
14        (2) the covered person or the covered person's
15    authorized representative filed a request for an expedited
16    internal review of an adverse determination pursuant to the
17    Managed Care Reform and Patient Rights Act and has not
18    received a decision on such request from the health carrier
19    within 48 hours, except to the extent the covered person or
20    the covered person's authorized representative requested
21    or agreed to a delay; or
22        (3) the health carrier agrees to waive the exhaustion
23    requirement; .
24        (4) the covered person has a medical condition in which
25    the timeframe for completion of (A) an expedited internal
26    review of a appeal involving an adverse determination, (B)

 

 

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1    a final adverse determination, or (C) a standard external
2    review as established in this Act would seriously
3    jeopardize the life or health of the covered person or
4    would jeopardize the covered person's ability to regain
5    maximum function;
6        (5) an adverse determination concerns a denial of
7    coverage based on a determination that the recommended or
8    requested health care service or treatment is experimental
9    or investigational and the covered person's health care
10    provider certifies in writing that the recommended or
11    requested health care service or treatment that is the
12    subject of the request would be significantly less
13    effective if not promptly initiated; in such cases, the
14    covered person or the covered person's authorized
15    representative may request an expedited external review at
16    the same time the covered person or the covered person's
17    authorized representative files a request for an expedited
18    internal appeal involving an adverse determination; the
19    independent review organization assigned to conduct the
20    expedited external review shall determine whether the
21    covered person is required to complete the expedited review
22    of the appeal prior to conducting the expedited external
23    review; or
24        (6) the health carrier has failed to comply with
25    applicable State and federal law governing internal claims
26    and appeals procedures.

 

 

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1(Source: P.A. 96-857, eff. 7-1-10.)
 
2    (215 ILCS 180/35)
3    Sec. 35. Standard external review.
4    (a) Within 4 months after the date of receipt of a notice
5of an adverse determination or final adverse determination, a
6covered person or the covered person's authorized
7representative may file a request for an external review with
8the Director. Within one business day after the date of receipt
9of a request for external review, the Director shall send a
10copy of the request to the health carrier.
11    (b) Within 5 business days following the date of receipt of
12the external review request, the health carrier shall complete
13a preliminary review of the request to determine whether:
14        (1) the individual is or was a covered person in the
15    health benefit plan at the time the health care service was
16    requested or at the time the health care service was
17    provided;
18        (2) the health care service that is the subject of the
19    adverse determination or the final adverse determination
20    is a covered service under the covered person's health
21    benefit plan, but the health carrier has determined that
22    the health care service is not covered because it does not
23    meet the health carrier's requirements for medical
24    necessity, appropriateness, health care setting, level of
25    care, or effectiveness;

 

 

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1        (3) the covered person has exhausted the health
2    carrier's internal appeal grievance process unless the
3    covered person is not required to exhaust the health
4    carrier's internal appeal process pursuant to as set forth
5    in this Act;
6        (4) (blank); and for appeals relating to a
7    determination based on treatment being experimental or
8    investigational, the requested health care service or
9    treatment that is the subject of the adverse determination
10    or final adverse determination is a covered benefit under
11    the covered person's health benefit plan except for the
12    health carrier's determination that the service or
13    treatment is experimental or investigational for a
14    particular medical condition and is not explicitly listed
15    as an excluded benefit under the covered person's health
16    benefit plan with the health carrier and that the covered
17    person's health care provider, who ordered or provided the
18    services in question and who is licensed under the Medical
19    Practice Act of 1987, has certified that one of the
20    following situations is applicable:
21            (A) standard health care services or treatments
22        have not been effective in improving the condition of
23        the covered person;
24            (B) standard health care services or treatments
25        are not medically appropriate for the covered person;
26            (C) there is no available standard health care

 

 

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1        service or treatment covered by the health carrier that
2        is more beneficial than the recommended or requested
3        health care service or treatment;
4            (D) the health care service or treatment is likely
5        to be more beneficial to the covered person, in the
6        health care provider's opinion, than any available
7        standard health care services or treatments; or
8            (E) that scientifically valid studies using
9        accepted protocols demonstrate that the health care
10        service or treatment requested is likely to be more
11        beneficial to the covered person than any available
12        standard health care services or treatments; and
13        (5) the covered person has provided all the information
14    and forms required to process an external review, as
15    specified in this Act.
16    (c) Within one business day after completion of the
17preliminary review, the health carrier shall notify the
18Director and covered person and, if applicable, the covered
19person's authorized representative in writing whether the
20request is complete and eligible for external review. If the
21request:
22        (1) is not complete, the health carrier shall inform
23    the Director and covered person and, if applicable, the
24    covered person's authorized representative in writing and
25    include in the notice what information or materials are
26    required by this Act to make the request complete; or

 

 

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1        (2) is not eligible for external review, the health
2    carrier shall inform the Director and covered person and,
3    if applicable, the covered person's authorized
4    representative in writing and include in the notice the
5    reasons for its ineligibility.
6    The Department may specify the form for the health
7carrier's notice of initial determination under this
8subsection (c) and any supporting information to be included in
9the notice.
10    The notice of initial determination of ineligibility shall
11include a statement informing the covered person and, if
12applicable, the covered person's authorized representative
13that a health carrier's initial determination that the external
14review request is ineligible for review may be appealed to the
15Director by filing a complaint with the Director.
16    Notwithstanding a health carrier's initial determination
17that the request is ineligible for external review, the
18Director may determine that a request is eligible for external
19review and require that it be referred for external review. In
20making such determination, the Director's decision shall be in
21accordance with the terms of the covered person's health
22benefit plan, unless such terms are inconsistent with
23applicable law, and shall be subject to all applicable
24provisions of this Act.
25    (d) Whenever the Director receives notice that a request is
26eligible for external review following the preliminary review

 

 

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

 

 

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1in accordance with this Section shall be done on a random basis
2among those independent review organizations approved by the
3Director pursuant to this Act. The assignment of an approved
4independent review organization to conduct an external review
5in accordance with this Section shall be made from those
6approved independent review organizations qualified to conduct
7external review as required by Sections 50 and 55 of this Act.
8    (f) Within Upon assignment of an independent review
9organization, the health carrier or its designee utilization
10review organization shall, within 5 business days after the
11date of receipt of the notice provided pursuant to item (1) of
12subsection (d) of this Section, the health carrier or its
13designee utilization review organization shall provide to the
14assigned independent review organization the documents and any
15information considered in making the adverse determination or
16final adverse determination; in such cases, the following
17provisions shall apply:
18        (1) Except as provided in item (2) of this subsection
19    (f), failure by the health carrier or its utilization
20    review organization to provide the documents and
21    information within the specified time frame shall not delay
22    the conduct of the external review.
23        (2) If the health carrier or its utilization review
24    organization fails to provide the documents and
25    information within the specified time frame, the assigned
26    independent review organization may terminate the external

 

 

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1    review and make a decision to reverse the adverse
2    determination or final adverse determination.
3        (3) Within one business day after making the decision
4    to terminate the external review and make a decision to
5    reverse the adverse determination or final adverse
6    determination under item (2) of this subsection (f), the
7    independent review organization shall notify the Director,
8    the health carrier, the covered person and, if applicable,
9    the covered person's authorized representative, of its
10    decision to reverse the adverse determination.
11    (g) Upon receipt of the information from the health carrier
12or its utilization review organization, the assigned
13independent review organization shall review all of the
14information and documents and any other information submitted
15in writing to the independent review organization by the
16covered person and the covered person's authorized
17representative.
18    (h) Upon receipt of any information submitted by the
19covered person or the covered person's authorized
20representative, the independent review organization shall
21forward the information to the health carrier within 1 business
22day.
23        (1) Upon receipt of the information, if any, the health
24    carrier may reconsider its adverse determination or final
25    adverse determination that is the subject of the external
26    review.

 

 

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

 

 

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1to the extent the information or documents are available and
2the independent review organization considers them
3appropriate, shall consider the following in reaching a
4decision:
5        (1) the covered person's pertinent medical records;
6        (2) the covered person's health care provider's
7    recommendation;
8        (3) consulting reports from appropriate health care
9    providers and other documents submitted by the health
10    carrier or its designee utilization review organization,
11    the covered person, the covered person's authorized
12    representative, or the covered person's treating provider;
13        (4) the terms of coverage under the covered person's
14    health benefit plan with the health carrier to ensure that
15    the independent review organization's decision is not
16    contrary to the terms of coverage under the covered
17    person's health benefit plan with the health carrier,
18    unless the terms are inconsistent with applicable law;
19        (5) the most appropriate practice guidelines, which
20    shall include applicable evidence-based standards and may
21    include any other practice guidelines developed by the
22    federal government, national or professional medical
23    societies, boards, and associations;
24        (6) any applicable clinical review criteria developed
25    and used by the health carrier or its designee utilization
26    review organization; and

 

 

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1        (7) the opinion of the independent review
2    organization's clinical reviewer or reviewers after
3    considering items (1) through (6) of this subsection (i) to
4    the extent the information or documents are available and
5    the clinical reviewer or reviewers considers the
6    information or documents appropriate; and
7        (8) (blank). for a denial of coverage based on a
8    determination that the health care service or treatment
9    recommended or requested is experimental or
10    investigational, whether and to what extent:
11            (A) the recommended or requested health care
12        service or treatment has been approved by the federal
13        Food and Drug Administration, if applicable, for the
14        condition;
15            (B) medical or scientific evidence or
16        evidence-based standards demonstrate that the expected
17        benefits of the recommended or requested health care
18        service or treatment is more likely than not to be
19        beneficial to the covered person than any available
20        standard health care service or treatment and the
21        adverse risks of the recommended or requested health
22        care service or treatment would not be substantially
23        increased over those of available standard health care
24        services or treatments; or
25            (C) the terms of coverage under the covered
26        person's health benefit plan with the health carrier to

 

 

09700HB0224sam001- 30 -LRB097 05693 RPM 55431 a

1        ensure that the health care service or treatment that
2        is the subject of the opinion is experimental or
3        investigational would otherwise be covered under the
4        terms of coverage of the covered person's health
5        benefit plan with the health carrier.
6    (j) Within 5 days after the date of receipt of all
7necessary information, but in no event more than 45 days after
8the date of receipt of the request for an external review, the
9assigned independent review organization shall provide written
10notice of its decision to uphold or reverse the adverse
11determination or the final adverse determination to the
12Director, the health carrier, the covered person, and, if
13applicable, the covered person's authorized representative. In
14reaching a decision, the assigned independent review
15organization is not bound by any claim determinations reached
16prior to the submission of information to the independent
17review organization. In such cases, the following provisions
18shall apply:
19        (1) The independent review organization shall include
20    in the notice:
21            (A) a general description of the reason for the
22        request for external review;
23            (B) the date the independent review organization
24        received the assignment from the Director health
25        carrier to conduct the external review;
26            (C) the time period during which the external

 

 

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1        review was conducted;
2            (D) references to the evidence or documentation,
3        including the evidence-based standards, considered in
4        reaching its decision;
5            (E) the date of its decision; and
6            (F) the principal reason or reasons for its
7        decision, including what applicable, if any,
8        evidence-based standards that were a basis for its
9        decision; and .
10            (G) the rationale for its decision.
11        (2) (Blank). For reviews of experimental or
12    investigational treatments, the notice shall include the
13    following information:
14            (A) a description of the covered person's medical
15        condition;
16            (B) a description of the indicators relevant to
17        whether there is sufficient evidence to demonstrate
18        that the recommended or requested health care service
19        or treatment is more likely than not to be more
20        beneficial to the covered person than any available
21        standard health care services or treatments and the
22        adverse risks of the recommended or requested health
23        care service or treatment would not be substantially
24        increased over those of available standard health care
25        services or treatments;
26            (C) a description and analysis of any medical or

 

 

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1        scientific evidence considered in reaching the
2        opinion;
3            (D) a description and analysis of any
4        evidence-based standards;
5            (E) whether the recommended or requested health
6        care service or treatment has been approved by the
7        federal Food and Drug Administration, for the
8        condition;
9            (F) whether medical or scientific evidence or
10        evidence-based standards demonstrate that the expected
11        benefits of the recommended or requested health care
12        service or treatment is more likely than not to be more
13        beneficial to the covered person than any available
14        standard health care service or treatment and the
15        adverse risks of the recommended or requested health
16        care service or treatment would not be substantially
17        increased over those of available standard health care
18        services or treatments; and
19            (G) the written opinion of the clinical reviewer,
20        including the reviewer's recommendation as to whether
21        the recommended or requested health care service or
22        treatment should be covered and the rationale for the
23        reviewer's recommendation.
24        (3) (Blank). In reaching a decision, the assigned
25    independent review organization is not bound by any
26    decisions or conclusions reached during the health

 

 

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1    carrier's utilization review process or the health
2    carrier's internal grievance or appeals process.
3        (4) Upon receipt of a notice of a decision reversing
4    the adverse determination or final adverse determination,
5    the health carrier immediately shall approve the coverage
6    that was the subject of the adverse determination or final
7    adverse determination.
8(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)
 
9    (215 ILCS 180/40)
10    Sec. 40. Expedited external review.
11    (a) A covered person or a covered person's authorized
12representative may file a request for an expedited external
13review with the Director health carrier either orally or in
14writing:
15        (1) immediately after the date of receipt of a notice
16    prior to a final adverse determination as provided by
17    subsection (b) of Section 20 of this Act;
18        (2) immediately after the date of receipt of a notice
19    upon a final adverse determination as provided by
20    subsection (c) of Section 20 of this Act; or
21        (3) if a health carrier fails to provide a decision on
22    request for an expedited internal appeal within 48 hours as
23    provided by item (2) of Section 30 of this Act.
24    (b) Upon receipt of a request for an expedited external
25review, the Director shall immediately send a copy of the

 

 

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1request to the health carrier. Immediately upon receipt of the
2request for an expedited external review as provided under
3subsections (b) and (c) of Section 20, the health carrier shall
4determine whether the request meets the reviewability
5requirements set forth in items (1), (2), and (4) of subsection
6(b) of Section 35. In such cases, the following provisions
7shall apply:
8        (1) The health carrier shall immediately notify the
9    Director, the covered person, and, if applicable, the
10    covered person's authorized representative of its
11    eligibility determination.
12        (2) The notice of initial determination shall include a
13    statement informing the covered person and, if applicable,
14    the covered person's authorized representative that a
15    health carrier's initial determination that an external
16    review request is ineligible for review may be appealed to
17    the Director.
18        (3) The Director may determine that a request is
19    eligible for expedited external review notwithstanding a
20    health carrier's initial determination that the request is
21    ineligible and require that it be referred for external
22    review.
23        (4) In making a determination under item (3) of this
24    subsection (b), the Director's decision shall be made in
25    accordance with the terms of the covered person's health
26    benefit plan, unless such terms are inconsistent with

 

 

09700HB0224sam001- 35 -LRB097 05693 RPM 55431 a

1    applicable law, and shall be subject to all applicable
2    provisions of this Act.
3        (5) The Director may specify the form for the health
4    carrier's notice of initial determination under this
5    subsection (b) and any supporting information to be
6    included in the notice.
7    (c) Upon receipt of the notice that the request meets the
8reviewability requirements, determining that a request meets
9the requirements of subsections (b) and (c) of Section 20, the
10Director health carrier shall immediately assign an
11independent review organization from the list of approved
12independent review organizations compiled and maintained by
13the Director to conduct the expedited review. In such cases,
14the following provisions shall apply:
15        (1) The assignment of an approved independent review
16    organization to conduct an external review in accordance
17    with this Section shall be made from those approved
18    independent review organizations qualified to conduct
19    external review as required by Sections 50 and 55 of this
20    Act.
21        (2) The Director shall immediately notify the health
22    carrier of the name of the assigned independent review
23    organization. Immediately upon receipt from the Director
24    of the name of the independent review organization assigned
25    to conduct the external review assigning an independent
26    review organization to perform an expedited external

 

 

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1    review, but in no case more than 24 hours after receiving
2    such notice assigning the independent review organization,
3    the health carrier or its designee utilization review
4    organization shall provide or transmit all necessary
5    documents and information considered in making the adverse
6    determination or final adverse determination to the
7    assigned independent review organization electronically or
8    by telephone or facsimile or any other available
9    expeditious method.
10        (3) If the health carrier or its utilization review
11    organization fails to provide the documents and
12    information within the specified timeframe, the assigned
13    independent review organization may terminate the external
14    review and make a decision to reverse the adverse
15    determination or final adverse determination.
16        (4) Within one business day after making the decision
17    to terminate the external review and make a decision to
18    reverse the adverse determination or final adverse
19    determination under item (3) of this subsection (c), the
20    independent review organization shall notify the Director,
21    the health carrier, the covered person, and, if applicable,
22    the covered person's authorized representative of its
23    decision to reverse the adverse determination or final
24    adverse determination.
25    (d) In addition to the documents and information provided
26by the health carrier or its utilization review organization

 

 

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1and any documents and information provided by the covered
2person and the covered person's authorized representative, the
3independent review organization, to the extent the information
4or documents are available and the independent review
5organization considers them appropriate, shall consider
6information as required by subsection (i) of Section 35 of this
7Act in reaching a decision.
8    (e) As expeditiously as the covered person's medical
9condition or circumstances requires, but in no event more than
1072 hours after the date of receipt of the request for an
11expedited external review 2 business days after the receipt of
12all pertinent information, the assigned independent review
13organization shall:
14        (1) make a decision to uphold or reverse the final
15    adverse determination; and
16        (2) notify the Director, the health carrier, the
17    covered person, the covered person's health care provider,
18    and, if applicable, the covered person's authorized
19    representative, of the decision.
20    (f) In reaching a decision, the assigned independent review
21organization is not bound by any decisions or conclusions
22reached during the health carrier's utilization review process
23or the health carrier's internal appeal grievance process as
24set forth in the Managed Care Reform and Patient Rights Act.
25    (g) Upon receipt of notice of a decision reversing the
26adverse determination or final adverse determination, the

 

 

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1health carrier shall immediately approve the coverage that was
2the subject of the adverse determination or final adverse
3determination.
4    (h) If the notice provided pursuant to subsection (e) of
5this Section was not in writing, then within Within 48 hours
6after the date of providing that the notice required in item
7(2) of subsection (e), the assigned independent review
8organization shall provide written confirmation of the
9decision to the Director, the health carrier, the covered
10person, and, if applicable, the covered person's authorized
11representative including the information set forth in
12subsection (j) of Section 35 of this Act as applicable.
13    (i) An expedited external review may not be provided for
14retrospective adverse or final adverse determinations.
15    (j) The assignment by the Director of an approved
16independent review organization to conduct an external review
17in accordance with this Section shall be done on a random basis
18among those independent review organizations approved by the
19Director pursuant to this Act.
20(Source: P.A. 96-857, eff. 7-1-10; revised 9-16-10.)
 
21    (215 ILCS 180/42 new)
22    Sec. 42. External review of experimental or
23investigational treatment adverse determinations.
24    (a) Within 4 months after the date of receipt of a notice
25of an adverse determination or final adverse determination that

 

 

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1involves a denial of coverage based on a determination that the
2health care service or treatment recommended or requested is
3experimental or investigational, a covered person or the
4covered person's authorized representative may file a request
5for an external review with the Director.
6    (b) The following provisions apply to cases concerning
7expedited external reviews:
8        (1) A covered person or the covered person's authorized
9    representative may make an oral request for an expedited
10    external review of the adverse determination or final
11    adverse determination pursuant to subsection (a) of this
12    Section if the covered person's treating physician
13    certifies, in writing, that the recommended or requested
14    health care service or treatment that is the subject of the
15    request would be significantly less effective if not
16    promptly initiated.
17        (2) Upon receipt of a request for an expedited external
18    review, the Director shall immediately notify the health
19    carrier.
20        (3) The following provisions apply concerning notice:
21            (A) Upon notice of the request for an expedited
22        external review, the health carrier shall immediately
23        determine whether the request meets the reviewability
24        requirements of subsection (d) of this Section. The
25        health carrier shall immediately notify the Director
26        and the covered person and, if applicable, the covered

 

 

09700HB0224sam001- 40 -LRB097 05693 RPM 55431 a

1        person's authorized representative of its eligibility
2        determination.
3            (B) The Director may specify the form for the
4        health carrier's notice of initial determination under
5        subdivision (A) of this item (3) and any supporting
6        information to be included in the notice.
7            (C) The notice of initial determination under
8        subdivision (A) of this item (3) shall include a
9        statement informing the covered person and, if
10        applicable, the covered person's authorized
11        representative that a health carrier's initial
12        determination that the external review request is
13        ineligible for review may be appealed to the Director.
14        (4) The following provisions apply concerning the
15    Director's determination:
16            (A) The Director may determine that a request is
17        eligible for external review under subsection (d) of
18        this Section notwithstanding a health carrier's
19        initial determination that the request is ineligible
20        and require that it be referred for external review.
21            (B) In making a determination under subdivision
22        (A) of this item (4), the Director's decision shall be
23        made in accordance with the terms of the covered
24        person's health benefit plan, unless such terms are
25        inconsistent with applicable law, and shall be subject
26        to all applicable provisions of this Act.

 

 

09700HB0224sam001- 41 -LRB097 05693 RPM 55431 a

1        (5) Upon receipt of the notice that the expedited
2    external review request meets the reviewability
3    requirements of subsection (d) of this Section, the
4    Director shall immediately assign an independent review
5    organization to review the expedited request from the list
6    of approved independent review organizations compiled and
7    maintained by the Director and notify the health carrier of
8    the name of the assigned independent review organization.
9        (6) At the time the health carrier receives the notice
10    of the assigned independent review organization, the
11    health carrier or its designee utilization review
12    organization shall provide or transmit all necessary
13    documents and information considered in making the adverse
14    determination or final adverse determination to the
15    assigned independent review organization electronically or
16    by telephone or facsimile or any other available
17    expeditious method.
18    (c) Except for a request for an expedited external review
19made pursuant to subsection (b) of this Section, within one
20business day after the date of receipt of a request for
21external review, the Director shall send a copy of the request
22to the health carrier.
23    (d) Within 5 business days following the date of receipt of
24the external review request, the health carrier shall complete
25a preliminary review of the request to determine whether:
26        (1) the individual is or was a covered person in the

 

 

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1    health benefit plan at the time the health care service was
2    recommended or requested or, in the case of a retrospective
3    review, at the time the health care service was provided;
4        (2) the recommended or requested health care service or
5    treatment that is the subject of the adverse determination
6    or final adverse determination is a covered benefit under
7    the covered person's health benefit plan except for the
8    health carrier's determination that the service or
9    treatment is experimental or investigational for a
10    particular medical condition and is not explicitly listed
11    as an excluded benefit under the covered person's health
12    benefit plan with the health carrier;
13        (3) the covered person's health care provider has
14    certified that one of the following situations is
15    applicable:
16            (A) standard health care services or treatments
17        have not been effective in improving the condition of
18        the covered person;
19            (B) standard health care services or treatments
20        are not medically appropriate for the covered person;
21        or
22            (C) there is no available standard health care
23        service or treatment covered by the health carrier that
24        is more beneficial than the recommended or requested
25        health care service or treatment;
26        (4) the covered person's health care provider:

 

 

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1            (A) has recommended a health care service or
2        treatment that the physician certifies, in writing, is
3        likely to be more beneficial to the covered person, in
4        the physician's opinion, than any available standard
5        health care services or treatments; or
6            (B) who is a licensed, board certified or board
7        eligible physician qualified to practice in the area of
8        medicine appropriate to treat the covered person's
9        condition, has certified in writing that
10        scientifically valid studies using accepted protocols
11        demonstrate that the health care service or treatment
12        requested by the covered person that is the subject of
13        the adverse determination or final adverse
14        determination is likely to be more beneficial to the
15        covered person than any available standard health care
16        services or treatments;
17        (5) the covered person has exhausted the health
18    carrier's internal appeal process, unless the covered
19    person is not required to exhaust the health carrier's
20    internal appeal process pursuant to Section 30 of this Act;
21    and
22        (6) the covered person has provided all the information
23    and forms required to process an external review, as
24    specified in this Act.
25    (e) The following provisions apply concerning requests:
26        (1) Within one business day after completion of the

 

 

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1    preliminary review, the health carrier shall notify the
2    Director and covered person and, if applicable, the covered
3    person's authorized representative in writing whether the
4    request is complete and eligible for external review.
5        (2) If the request:
6            (A) is not complete, then the health carrier shall
7        inform the Director and the covered person and, if
8        applicable, the covered person's authorized
9        representative in writing and include in the notice
10        what information or materials are required by this Act
11        to make the request complete; or
12            (B) is not eligible for external review, then the
13        health carrier shall inform the Director and the
14        covered person and, if applicable, the covered
15        person's authorized representative in writing and
16        include in the notice the reasons for its
17        ineligibility.
18        (3) The Department may specify the form for the health
19    carrier's notice of initial determination under this
20    subsection (e) and any supporting information to be
21    included in the notice.
22        (4) The notice of initial determination of
23    ineligibility shall include a statement informing the
24    covered person and, if applicable, the covered person's
25    authorized representative that a health carrier's initial
26    determination that the external review request is

 

 

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1    ineligible for review may be appealed to the Director by
2    filing a complaint with the Director.
3        (5) Notwithstanding a health carrier's initial
4    determination that the request is ineligible for external
5    review, the Director may determine that a request is
6    eligible for external review and require that it be
7    referred for external review. In making such
8    determination, the Director's decision shall be in
9    accordance with the terms of the covered person's health
10    benefit plan, unless such terms are inconsistent with
11    applicable law, and shall be subject to all applicable
12    provisions of this Act.
13    (f) Whenever a request for external review is determined
14eligible for external review, the health carrier shall notify
15the Director and the covered person and, if applicable, the
16covered person's authorized representative.
17    (g) Whenever the Director receives notice that a request is
18eligible for external review following the preliminary review
19conducted pursuant to this Section, within one business day
20after the date of receipt of the notice, the Director shall:
21        (1) assign an independent review organization from the
22    list of approved independent review organizations compiled
23    and maintained by the Director pursuant to this Act and
24    notify the health carrier of the name of the assigned
25    independent review organization; and
26        (2) notify in writing the covered person and, if

 

 

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1    applicable, the covered person's authorized representative
2    of the request's eligibility and acceptance for external
3    review and the name of the independent review organization.
4    The Director shall include in the notice provided to the
5covered person and, if applicable, the covered person's
6authorized representative a statement that the covered person
7or the covered person's authorized representative may, within 5
8business days following the date of receipt of the notice
9provided pursuant to item (2) of this subsection (g), submit in
10writing to the assigned independent review organization
11additional information that the independent review
12organization shall consider when conducting the external
13review. The independent review organization is not required to,
14but may, accept and consider additional information submitted
15after 5 business days.
16    (h) The following provisions apply concerning assignments
17and clinical reviews:
18        (1) Within one business day after the receipt of the
19    notice of assignment to conduct the external review
20    pursuant to subsection (g) of this Section, the assigned
21    independent review organization shall select one or more
22    clinical reviewers, as it determines is appropriate,
23    pursuant to item (2) of this subsection (h) to conduct the
24    external review.
25        (2) The provisions of this item (2) apply concerning
26    the selection of reviewers:

 

 

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1            (A) In selecting clinical reviewers pursuant to
2        item (1) of this subsection (h), the assigned
3        independent review organization shall select
4        physicians or other health care professionals who meet
5        the minimum qualifications described in Section 55 of
6        this Act and, through clinical experience in the past 3
7        years, are experts in the treatment of the covered
8        person's condition and knowledgeable about the
9        recommended or requested health care service or
10        treatment.
11            (B) Neither the covered person, the covered
12        person's authorized representative, if applicable, nor
13        the health carrier shall choose or control the choice
14        of the physicians or other health care professionals to
15        be selected to conduct the external review.
16        (3) In accordance with subsection (l) of this Section,
17    each clinical reviewer shall provide a written opinion to
18    the assigned independent review organization on whether
19    the recommended or requested health care service or
20    treatment should be covered.
21        (4) In reaching an opinion, clinical reviewers are not
22    bound by any decisions or conclusions reached during the
23    health carrier's utilization review process or the health
24    carrier's internal appeal process.
25    (i) Within 5 business days after the date of receipt of the
26notice provided pursuant to subsection (g) of this Section, the

 

 

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

 

 

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1selected pursuant to subsection (h) of this Section shall
2review all of the information and documents and any other
3information submitted in writing to the independent review
4organization by the covered person and the covered person's
5authorized representative.
6    (k) Upon receipt of any information submitted by the
7covered person or the covered person's authorized
8representative, the independent review organization shall
9forward the information to the health carrier within one
10business day. In such cases, the following provisions shall
11apply:
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 be terminated only 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) Immediately upon making its decision to

 

 

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1        reverse its adverse determination or final adverse
2        determination, the health carrier shall notify the
3        Director, the covered person and, if applicable, the
4        covered person's authorized representative, and the
5        assigned independent review organization in writing of
6        its 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    (l) The following provisions apply concerning clinical
13review opinions:
14        (1) Except as provided in item (3) of this subsection
15    (l), within 20 days after being selected in accordance with
16    subsection (h) of this Section to conduct the external
17    review, each clinical reviewer shall provide an opinion to
18    the assigned independent review organization on whether
19    the recommended or requested health care service or
20    treatment should be covered.
21        (2) Except for an opinion provided pursuant to item (3)
22    of this subsection (l), each clinical reviewer's opinion
23    shall be in writing and include the following information:
24            (A) a description of the covered person's medical
25        condition;
26            (B) a description of the indicators relevant to

 

 

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1        determining whether there is sufficient evidence to
2        demonstrate that the recommended or requested health
3        care service or treatment is more likely than not to be
4        beneficial to the covered person than any available
5        standard health care services or treatments and the
6        adverse risks of the recommended or requested health
7        care service or treatment would not be substantially
8        increased over those of available standard health care
9        services or treatments;
10            (C) a description and analysis of any medical or
11        scientific evidence considered in reaching the
12        opinion;
13            (D) a description and analysis of any
14        evidence-based standard; and
15            (E) information on whether the reviewer's
16        rationale for the opinion is based on clause (A) or (B)
17        of item (5) of subsection (m) of this Section.
18        (3) The provisions of this item (3) apply concerning
19    the timing of opinions:
20            (A) For an expedited external review, each
21        clinical reviewer shall provide an opinion orally or in
22        writing to the assigned independent review
23        organization as expeditiously as the covered person's
24        medical condition or circumstances requires, but in no
25        event more than 5 calendar days after being selected in
26        accordance with subsection (h) of this Section.

 

 

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1            (B) If the opinion provided pursuant to
2        subdivision (A) of this item (3) was not in writing,
3        then within 48 hours following the date the opinion was
4        provided, the clinical reviewer shall provide written
5        confirmation of the opinion to the assigned
6        independent review organization and include the
7        information required under item (2) of this subsection
8        (l).
9    (m) In addition to the documents and information provided
10by the health carrier or its utilization review organization
11and the covered person and the covered person's authorized
12representative, if any, each clinical reviewer selected
13pursuant to subsection (h) of this Section, to the extent the
14information or documents are available and the clinical
15reviewer considers appropriate, shall consider the following
16in reaching a decision:
17        (1) the covered person's pertinent medical records;
18        (2) the covered person's health care provider's
19    recommendation;
20        (3) consulting reports from appropriate health care
21    providers and other documents submitted by the health
22    carrier or its designee utilization review organization,
23    the covered person, the covered person's authorized
24    representative, or the covered person's treating physician
25    or health care professional;
26        (4) the terms of coverage under the covered person's

 

 

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1    health benefit plan with the health carrier to ensure that,
2    but for the health carrier's determination that the
3    recommended or requested health care service or treatment
4    that is the subject of the opinion is experimental or
5    investigational, the reviewer's opinion is not contrary to
6    the terms of coverage under the covered person's health
7    benefit plan with the health carrier; and
8        (5) whether (A) the recommended or requested health
9    care service or treatment has been approved by the federal
10    Food and Drug Administration, if applicable, for the
11    condition or (B) medical or scientific evidence or
12    evidence-based standards demonstrate that the expected
13    benefits of the recommended or requested health care
14    service or treatment is more likely than not to be
15    beneficial to the covered person than any available
16    standard health care service or treatment and the adverse
17    risks of the recommended or requested health care service
18    or treatment would not be substantially increased over
19    those of available standard health care services or
20    treatments.
21    (n) The following provisions apply concerning decisions,
22notices, and recommendations:
23        (1) The provisions of this item (1) apply concerning
24    decisions and notices:
25            (A) Except as provided in subdivision (B) of this
26        item (1), within 20 days after the date it receives the

 

 

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1        opinion of each clinical reviewer, the assigned
2        independent review organization, in accordance with
3        item (2) of this subsection (n), shall make a decision
4        and provide written notice of the decision to the
5        Director, the health carrier, the covered person, and
6        the covered person's authorized representative, if
7        applicable.
8            (B) For an expedited external review, within 48
9        hours after the date it receives the opinion of each
10        clinical reviewer, the assigned independent review
11        organization, in accordance with item (2) of this
12        subsection (n), shall make a decision and provide
13        notice of the decision orally or in writing to the
14        Director, the health carrier, the covered person, and
15        the covered person's authorized representative, if
16        applicable. If such notice is not in writing, within 48
17        hours after the date of providing that notice, the
18        assigned independent review organization shall provide
19        written confirmation of the decision to the Director,
20        the health carrier, the covered person, and the covered
21        person's authorized representative, if applicable.
22        (2) The provisions of this item (2) apply concerning
23    recommendations:
24            (A) If a majority of the clinical reviewers
25        recommend that the recommended or requested health
26        care service or treatment should be covered, then the

 

 

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1        independent review organization shall make a decision
2        to reverse the health carrier's adverse determination
3        or final adverse determination.
4            (B) If a majority of the clinical reviewers
5        recommend that the recommended or requested health
6        care service or treatment should not be covered, the
7        independent review organization shall make a decision
8        to uphold the health carrier's adverse determination
9        or final adverse determination.
10            (C) The provisions of this subdivision (C) apply to
11        cases in which the clinical reviewers are evenly split:
12                (i) If the clinical reviewers are evenly split
13            as to whether the recommended or requested health
14            care service or treatment should be covered, then
15            the independent review organization shall obtain
16            the opinion of an additional clinical reviewer in
17            order for the independent review organization to
18            make a decision based on the opinions of a majority
19            of the clinical reviewers pursuant to subdivision
20            (A) or (B) of this item (2).
21                (ii) The additional clinical reviewer selected
22            under clause (i) of this subdivision (C) shall use
23            the same information to reach an opinion as the
24            clinical reviewers who have already submitted
25            their opinions.
26                (iii) The selection of the additional clinical

 

 

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1            reviewer under this subdivision (C) shall not
2            extend the time within which the assigned
3            independent review organization is required to
4            make a decision based on the opinions of the
5            clinical reviewers.
6    (o) The independent review organization shall include in
7the notice provided pursuant to subsection (n) of this Section:
8        (1) a general description of the reason for the request
9    for external review;
10        (2) the written opinion of each clinical reviewer,
11    including the recommendation of each clinical reviewer as
12    to whether the recommended or requested health care service
13    or treatment should be covered and the rationale for the
14    reviewer's recommendation;
15        (3) the date the independent review organization
16    received the assignment from the Director to conduct the
17    external review;
18        (4) the time period during which the external review
19    was conducted;
20        (5) the date of its decision;
21        (6) the principal reason or reasons for its decision;
22    and
23        (7) the rationale for its decision.
24    (p) Upon receipt of a notice of a decision reversing the
25adverse determination or final adverse determination, the
26health carrier shall immediately approve the coverage that was

 

 

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1the subject of the adverse determination or final adverse
2determination.
3    (q) The assignment by the Director of an approved
4independent review organization to conduct an external review
5in accordance with this Section shall be done on a random basis
6among those independent review organizations approved by the
7Director pursuant to this Act.
 
8    (215 ILCS 180/55)
9    Sec. 55. Minimum qualifications for independent review
10organizations.
11    (a) To be approved to conduct external reviews, an
12independent review organization shall have and maintain
13written policies and procedures that govern all aspects of both
14the standard external review process and the expedited external
15review process set forth in this Act that include, at a
16minimum:
17        (1) a quality assurance mechanism that ensures that:
18            (A) external reviews are conducted within the
19        specified timeframes and required notices are provided
20        in a timely manner;
21            (B) selection of qualified and impartial clinical
22        reviewers to conduct external reviews on behalf of the
23        independent review organization and suitable matching
24        of reviewers to specific cases and that the independent
25        review organization employs or contracts with an

 

 

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1        adequate number of clinical reviewers to meet this
2        objective;
3            (C) for adverse determinations involving
4        experimental or investigational treatments, in
5        assigning clinical reviewers, the independent review
6        organization selects physicians or other health care
7        professionals who, through clinical experience in the
8        past 3 years, are experts in the treatment of the
9        covered person's condition and knowledgeable about the
10        recommended or requested health care service or
11        treatment;
12            (D) the health carrier, the covered person, and the
13        covered person's authorized representative shall not
14        choose or control the choice of the physicians or other
15        health care professionals to be selected to conduct the
16        external review;
17            (E) confidentiality of medical and treatment
18        records and clinical review criteria; and
19            (F) any person employed by or under contract with
20        the independent review organization adheres to the
21        requirements of this Act;
22        (2) a toll-free telephone service operating on a
23    24-hour-day, 7-day-a-week basis that accepts, receives,
24    and records information related to external reviews and
25    provides appropriate instructions; and
26        (3) an agreement to maintain and provide to the

 

 

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1    Director the information set out in Section 70 of this Act.
2    (b) All clinical reviewers assigned by an independent
3review organization to conduct external reviews shall be
4physicians or other appropriate health care providers who meet
5the following minimum qualifications:
6        (1) be an expert in the treatment of the covered
7    person's medical condition that is the subject of the
8    external review;
9        (2) be knowledgeable about the recommended health care
10    service or treatment through recent or current actual
11    clinical experience treating patients with the same or
12    similar medical condition of the covered person;
13        (3) hold a non-restricted license in a state of the
14    United States and, for physicians, a current certification
15    by a recognized American medical specialty board in the
16    area or areas appropriate to the subject of the external
17    review; and
18        (4) have no history of disciplinary actions or
19    sanctions, including loss of staff privileges or
20    participation restrictions, that have been taken or are
21    pending by any hospital, governmental agency or unit, or
22    regulatory body that raise a substantial question as to the
23    clinical reviewer's physical, mental, or professional
24    competence or moral character.
25    (c) In addition to the requirements set forth in subsection
26(a), an independent review organization may not own or control,

 

 

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1be a subsidiary of, or in any way be owned, or controlled by,
2or exercise control with a health benefit plan, a national,
3State, or local trade association of health benefit plans, or a
4national, State, or local trade association of health care
5providers.
6    (d) Conflicts of interest prohibited. In addition to the
7requirements set forth in subsections (a), (b), and (c) of this
8Section, to be approved pursuant to this Act to conduct an
9external review of a specified case, neither the independent
10review organization selected to conduct the external review nor
11any clinical reviewer assigned by the independent organization
12to conduct the external review may have a material
13professional, familial or financial conflict of interest with
14any of the following:
15        (1) the health carrier that is the subject of the
16    external review;
17        (2) the covered person whose treatment is the subject
18    of the external review or the covered person's authorized
19    representative;
20        (3) any officer, director or management employee of the
21    health carrier that is the subject of the external review;
22        (4) the health care provider, the health care
23    provider's medical group or independent practice
24    association recommending the health care service or
25    treatment that is the subject of the external review;
26        (5) the facility at which the recommended health care

 

 

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1    service or treatment would be provided; or
2        (6) the developer or manufacturer of the principal
3    drug, device, procedure, or other therapy being
4    recommended for the covered person whose treatment is the
5    subject of the external review.
6    (e) An independent review organization that is accredited
7by a nationally recognized private accrediting entity that has
8independent review accreditation standards that the Director
9has determined are equivalent to or exceed the minimum
10qualifications of this Section shall be presumed to be in
11compliance with this Section and shall be eligible for approval
12under this Act.
13    (f) An independent review organization shall be unbiased.
14An independent review organization shall establish and
15maintain written procedures to ensure that it is unbiased in
16addition to any other procedures required under this Section.
17    (g) Nothing in this Act precludes or shall be interpreted
18to preclude a health carrier from contracting with approved
19independent review organizations to conduct external reviews
20assigned to it from such health carrier.
21(Source: P.A. 96-857, eff. 7-1-10.)
 
22    (215 ILCS 180/65)
23    Sec. 65. External review reporting requirements.
24    (a) Each health carrier shall maintain written records in
25the aggregate, by state, and for each type of health benefit

 

 

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1plan offered by the health carrier on all requests for external
2review that the health carrier received notice from the
3Director for each calendar year and submit a report to the
4Director in the format specified by the Director by March 1 of
5each year.
6    (a-5) An independent review organization assigned pursuant
7to this Act to conduct an external review shall maintain
8written records in the aggregate by state and by health carrier
9on all requests for external review for which it conducted an
10external review during a calendar year and submit a report in
11the format specified by the Director by March 1 of each year.
12    (a-10) The report required by subsection (a-5) shall
13include in the aggregate by state, and for each health carrier:
14        (1) the total number of requests for external review;
15        (2) the number of requests for external review resolved
16    and, of those resolved, the number resolved upholding the
17    adverse determination or final adverse determination and
18    the number resolved reversing the adverse determination or
19    final adverse determination;
20        (3) the average length of time for resolution;
21        (4) a summary of the types of coverages or cases for
22    which an external review was sought, as provided in the
23    format required by the Director;
24        (5) the number of external reviews that were terminated
25    as the result of a reconsideration by the health carrier of
26    its adverse determination or final adverse determination

 

 

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1    after the receipt of additional information from the
2    covered person or the covered person's authorized
3    representative; and
4        (6) any other information the Director may request or
5    require.
6    (a-15) The independent review organization shall retain
7the written records required pursuant to this Section for at
8least 3 years.
9    (b) The report required under subsection (a) of this
10Section shall include in the aggregate, by state, and by type
11of health benefit plan:
12        (1) the total number of requests for external review;
13        (2) the total number of requests for expedited external
14    review;
15        (3) the total number of requests for external review
16    denied;
17        (4) the number of requests for external review
18    resolved, including:
19            (A) the number of requests for external review
20        resolved upholding the adverse determination or final
21        adverse determination;
22            (B) the number of requests for external review
23        resolved reversing the adverse determination or final
24        adverse determination;
25            (C) the number of requests for expedited external
26        review resolved upholding the adverse determination or

 

 

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1        final adverse determination; and
2            (D) the number of requests for expedited external
3        review resolved reversing the adverse determination or
4        final adverse determination;
5        (5) the average length of time for resolution for an
6    external review;
7        (6) the average length of time for resolution for an
8    expedited external review;
9        (7) a summary of the types of coverages or cases for
10    which an external review was sought, as specified below:
11            (A) denial of care or treatment (dissatisfaction
12        regarding prospective non-authorization of a request
13        for care or treatment recommended by a provider
14        excluding diagnostic procedures and referral requests;
15        partial approvals and care terminations are also
16        considered to be denials);
17            (B) denial of diagnostic procedure
18        (dissatisfaction regarding prospective
19        non-authorization of a request for a diagnostic
20        procedure recommended by a provider; partial approvals
21        are also considered to be denials);
22            (C) denial of referral request (dissatisfaction
23        regarding non-authorization of a request for a
24        referral to another provider recommended by a PCP);
25            (D) claims and utilization review (dissatisfaction
26        regarding the concurrent or retrospective evaluation

 

 

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1        of the coverage, medical necessity, efficiency or
2        appropriateness of health care services or treatment
3        plans; prospective "Denials of care or treatment",
4        "Denials of diagnostic procedures" and "Denials of
5        referral requests" should not be classified in this
6        category, but the appropriate one above);
7        (8) the number of external reviews that were terminated
8    as the result of a reconsideration by the health carrier of
9    its adverse determination or final adverse determination
10    after the receipt of additional information from the
11    covered person or the covered person's authorized
12    representative; and
13        (9) any other information the Director may request or
14    require.
15(Source: P.A. 96-857, eff. 7-1-10.)
 
16    (215 ILCS 180/75)
17    Sec. 75. Disclosure requirements.
18    (a) Each health carrier shall include a description of the
19external review procedures in, or attached to, the policy,
20certificate, membership booklet, and outline of coverage or
21other evidence of coverage it provides to covered persons.
22    (b) The description required under subsection (a) of this
23Section shall include a statement that informs the covered
24person of the right of the covered person to file a request for
25an external review of an adverse determination or final adverse

 

 

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1determination with the Director health carrier. The statement
2shall explain that external review is available when the
3adverse determination or final adverse determination involves
4an issue of medical necessity, appropriateness, health care
5setting, level of care, or effectiveness. The statement shall
6include the toll-free telephone number and address of the
7Office of Consumer Health Insurance within the Department of
8Insurance.
9(Source: P.A. 96-857, eff. 7-1-10.)
 
10    (215 ILCS 180/80 new)
11    Sec. 80. Administration and enforcement.
12    (a) The Director of Insurance may adopt rules necessary to
13implement the Department's responsibilities under this Act.
14    (b) The Director is authorized to make use of any of the
15powers established under the Illinois Insurance Code to enforce
16the laws of this State. This includes but is not limited to,
17the Director's administrative authority to investigate, issue
18subpoenas, conduct depositions and hearings, issue orders,
19including, without limitation, orders pursuant to Article XII
201/2 and Section 401.1 of the Illinois Insurance Code, and
21impose penalties.
 
22    Section 99. Effective date. This Act takes effect on July
231, 2011.".