Synopsis As Introduced Creates the Prior Authorization Reform Act. Provides requirements concerning disclosure and review of prior authorization requirements, denial of claims or coverage by a utilization review organization, and the implementation of prior authorization requirements or restrictions. Provides requirements concerning a utilization review organization's obligations with respect to prior authorizations in nonurgent circumstances, urgent health care services, and emergency health care services. Provides that a utilization review organization shall not require prior authorization under specified circumstances. Provides requirements concerning the length of prior authorizations. Provides that health care services are automatically deemed authorized if a utilization review organization fails to comply with the requirements of the Act. Provides that the Director of Insurance may impose an administrative fine not to exceed $250,000 for violations of the Act. Defines terms. Amends the Illinois Insurance Code to change the definition of "emergency medical condition". Amends the Managed Care Reform and Patient Rights Act to provide that companies that transact accident and health insurance shall comply with specified requirements of the Managed Care Reform and Patient Rights Act. Amends the Illinois Public Aid Code to provide that all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act. Makes other changes. Effective January 1, 2022.
House Floor Amendment No. 1 Replaces everything after the enacting clause with the provisions of the introduced bill with the following changes. Changes references from "utilization review organization" to "health insurance issuer" or "health insurance issuer or its contracted utilization review organization". Provides that a health insurance issuer or its contracted utilization review organization must ensure that all adverse determinations are made by a physician when the request is by a physician or a representative of a physician. Provides that a health insurance issuer shall periodically review its prior authorization requirements and consider removal of prior authorization requirements in specified circumstances (rather than a utilization review organization shall not require prior authorization in specified circumstances). In provisions concerning length of prior authorization approval, provides that a prior authorization approval shall be valid for the lesser of 12 months after the date the health care professional or health care provider receives the prior authorization approval or the length of treatment as determined by the patient's health care professional. In provisions concerning clinical review criteria of prior authorization requirements, removes language that provides that a utilization review organization shall seek input from actively practicing physicians representing major areas of the specialty who are not employees of the utilization review organization or consultants to the utilization review organization before establishing or substantially or materially altering written clinical review criteria. Removes language that provides that a utilization review organization shall not deny prior authorization of a health care service solely based on the grounds that a health care professional or health care provider judges a service, product, or procedure is medically appropriate for his or her patient even if it has not been formally approved for the specific condition being treated. In provisions concerning statistics that shall be made available regarding prior authorization approvals and denials, removes specified categories of information. In provisions concerning requirements applicable to the physician who can review consultations and appeals, removes language that provides that the physician must not be employed by a utilization review organization, be under contract with the utilization review organization other than to participate in one or more of the utilization review organization's health care professional networks or to perform reviews of appeals, or otherwise have any financial interest in the outcome of the appeal. Makes other changes. Effective January 1, 2022.
Replaces everything after the enacting clause with the provisions of the introduced bill, and makes the following changes: In the Prior Authorization Reform Act, deletes a Section concerning obligations with respect to prior authorization concerning emergency health care services, and makes changes in provisions governing applicability; definitions; disclosure and review of prior authorization requirements; obligations with respect to prior authorizations; personnel qualified to make adverse determinations of a prior authorization request; adverse determinations; review of appeals; denials; length of prior authorization approval; continuity of care; effect of failure to comply with the Act; and administration and enforcement. Makes further changes in the Illinois Insurance Code in a Section concerning obligations under the Managed Care Reform and Patient Rights Act. Deletes changes made to the Managed Care Reform and Patient Rights Act in a Section concerning emergency services prior to stabilization. Effective January 1, 2022.