HB0224enr 97TH GENERAL ASSEMBLY

  
  
  

 


 
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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Health Carrier External Review Act is
5amended by changing 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
17    effectiveness or is determined to be experimental or
18    investigational and the requested benefit is therefore
19    denied, reduced, or terminated or payment is not provided
20    or made, in whole or in part, for the benefit;
21        (2) the denial, reduction, or termination of or failure
22    to provide or make payment, in whole or in part, for a
23    benefit based on a determination by a health carrier or its

 

 

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1    designee utilization review organization that a
2    preexisting condition was present before the effective
3    date of coverage; or
4        (3) a recission of coverage determination, which does
5    not include a cancellation or discontinuance of coverage
6    that is attributable to a failure to timely pay required
7    premiums or contributions towards the cost of coverage.
8    means a determination by a health carrier or its designee
9    utilization review organization that an admission,
10    availability of care, continued stay, or other health care
11    service that is a covered benefit has been reviewed and,
12    based upon the information provided, does not meet the
13    health carrier's requirements for medical necessity,
14    appropriateness, health care setting, level of care, or
15    effectiveness, and the requested service or payment for the
16    service is therefore denied, reduced, or terminated.
17    "Authorized representative" means:
18        (1) a person to whom a covered person has given express
19    written consent to represent the covered person for
20    purposes of this Law;
21        (2) a person authorized by law to provide substituted
22    consent for a covered person;
23        (3) a family member of the covered person or the
24    covered person's treating health care professional when
25    the covered person is unable to provide consent;
26        (4) a health care provider when the covered person's

 

 

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1    health benefit plan requires that a request for a benefit
2    under the plan be initiated by the health care provider; or
3        (5) in the case of an urgent care request, a health
4    care provider with knowledge of the covered person's
5    medical condition.
6        (1) a person to whom a covered person has given express
7    written consent to represent the covered person in an
8    external review, including the covered person's health
9    care provider;
10        (2) a person authorized by law to provide substituted
11    consent for a covered person; or
12        (3) the covered person's health care provider when the
13    covered person is unable to provide consent.
14    "Best evidence" means evidence based on:
15        (1) randomized clinical trials;
16        (2) if randomized clinical trials are not available,
17    then cohort studies or case-control studies;
18        (3) if items (1) and (2) are not available, then
19    case-series; or
20        (4) if items (1), (2), and (3) are not available, then
21    expert opinion.
22    "Case-series" means an evaluation of a series of patients
23with a particular outcome, without the use of a control group.
24    "Clinical review criteria" means the written screening
25procedures, decision abstracts, clinical protocols, and
26practice guidelines used by a health carrier to determine the

 

 

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1necessity and appropriateness of health care services.
2    "Cohort study" means a prospective evaluation of 2 groups
3of patients with only one group of patients receiving specific
4intervention.
5    "Concurrent review" means a review conducted during a
6patient's stay or course of treatment in a facility, the office
7of a health care professional, or other inpatient or outpatient
8health care setting.
9    "Covered benefits" or "benefits" means those health care
10services to which a covered person is entitled under the terms
11of a health benefit plan.
12    "Covered person" means a policyholder, subscriber,
13enrollee, or other individual participating in a health benefit
14plan.
15    "Director" means the Director of the Department of
16Insurance.
17    "Emergency medical condition" means a medical condition
18manifesting itself by acute symptoms of sufficient severity,
19including, but not limited to, severe pain, such that a prudent
20layperson who possesses an average knowledge of health and
21medicine could reasonably expect the absence of immediate
22medical attention to result in:
23        (1) placing the health of the individual or, with
24    respect to a pregnant woman, the health of the woman or her
25    unborn child, in serious jeopardy;
26        (2) serious impairment to bodily functions; or

 

 

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1        (3) serious dysfunction of any bodily organ or part.
2    "Emergency services" means health care items and services
3furnished or required to evaluate and treat an emergency
4medical condition.
5    "Evidence-based standard" means the conscientious,
6explicit, and judicious use of the current best evidence based
7on an overall systematic review of the research in making
8decisions about the care of individual patients.
9    "Expert opinion" means a belief or an interpretation by
10specialists with experience in a specific area about the
11scientific evidence pertaining to a particular service,
12intervention, or therapy.
13    "Facility" means an institution providing health care
14services or a health care setting.
15    "Final adverse determination" means an adverse
16determination involving a covered benefit that has been upheld
17by a health carrier, or its designee utilization review
18organization, at the completion of the health carrier's
19internal grievance process procedures as set forth by the
20Managed Care Reform and Patient Rights Act.
21    "Health benefit plan" means a policy, contract,
22certificate, plan, or agreement offered or issued by a health
23carrier to provide, deliver, arrange for, pay for, or reimburse
24any of the costs of health care services.
25    "Health care provider" or "provider" means a physician,
26hospital facility, or other health care practitioner licensed,

 

 

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1accredited, or certified to perform specified health care
2services consistent with State law, responsible for
3recommending health care services on behalf of a covered
4person.
5    "Health care services" means services for the diagnosis,
6prevention, treatment, cure, or relief of a health condition,
7illness, injury, or disease.
8    "Health carrier" means an entity subject to the insurance
9laws and regulations of this State, or subject to the
10jurisdiction of the Director, that contracts or offers to
11contract to provide, deliver, arrange for, pay for, or
12reimburse any of the costs of health care services, including a
13sickness and accident insurance company, a health maintenance
14organization, or any other entity providing a plan of health
15insurance, health benefits, or health care services. "Health
16carrier" also means Limited Health Service Organizations
17(LHSO) and Voluntary Health Service Plans.
18    "Health information" means information or data, whether
19oral or recorded in any form or medium, and personal facts or
20information about events or relationships that relate to:
21        (1) the past, present, or future physical, mental, or
22    behavioral health or condition of an individual or a member
23    of the individual's family;
24        (2) the provision of health care services to an
25    individual; or
26        (3) payment for the provision of health care services

 

 

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1    to an individual.
2    "Independent review organization" means an entity that
3conducts independent external reviews of adverse
4determinations and final adverse determinations.
5    "Medical or scientific evidence" means evidence found in
6the following sources:
7        (1) peer-reviewed scientific studies published in or
8    accepted for publication by medical journals that meet
9    nationally recognized requirements for scientific
10    manuscripts and that submit most of their published
11    articles for review by experts who are not part of the
12    editorial staff;
13        (2) peer-reviewed medical literature, including
14    literature relating to therapies reviewed and approved by a
15    qualified institutional review board, biomedical
16    compendia, and other medical literature that meet the
17    criteria of the National Institutes of Health's Library of
18    Medicine for indexing in Index Medicus (Medline) and
19    Elsevier Science Ltd. for indexing in Excerpta Medicus
20    (EMBASE);
21        (3) medical journals recognized by the Secretary of
22    Health and Human Services under Section 1861(t)(2) of the
23    federal Social Security Act;
24        (4) the following standard reference compendia:
25            (a) The American Hospital Formulary Service-Drug
26        Information;

 

 

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1            (b) Drug Facts and Comparisons;
2            (c) The American Dental Association Accepted
3        Dental Therapeutics; and
4            (d) The United States Pharmacopoeia-Drug
5        Information;
6        (5) findings, studies, or research conducted by or
7    under the auspices of federal government agencies and
8    nationally recognized federal research institutes,
9    including:
10            (a) the federal Agency for Healthcare Research and
11        Quality;
12            (b) the National Institutes of Health;
13            (c) the National Cancer Institute;
14            (d) the National Academy of Sciences;
15            (e) the Centers for Medicare & Medicaid Services;
16            (f) the federal Food and Drug Administration; and
17            (g) any national board recognized by the National
18        Institutes of Health for the purpose of evaluating the
19        medical value of health care services; or
20        (6) any other medical or scientific evidence that is
21    comparable to the sources listed in items (1) through (5).
22    "Person" means an individual, a corporation, a
23partnership, an association, a joint venture, a joint stock
24company, a trust, an unincorporated organization, any similar
25entity, or any combination of the foregoing.
26    "Prospective review" means a review conducted prior to an

 

 

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1admission or the provision of a health care service or a course
2of treatment in accordance with a health carrier's requirement
3that the health care service or course of treatment, in whole
4or in part, be approved prior to its provision.
5    "Protected health information" means health information
6(i) that identifies an individual who is the subject of the
7information; or (ii) with respect to which there is a
8reasonable basis to believe that the information could be used
9to identify an individual.
10    "Randomized clinical trial" means a controlled prospective
11study of patients that have been randomized into an
12experimental group and a control group at the beginning of the
13study with only the experimental group of patients receiving a
14specific intervention, which includes study of the groups for
15variables and anticipated outcomes over time.
16    "Retrospective review" means any review of a request for a
17benefit that is not a concurrent or prospective review request.
18"Retrospective review" does not include the review of a claim
19that is limited to veracity of documentation or accuracy of
20coding. means a review of medical necessity conducted after
21services have been provided to a patient, but does not include
22the review of a claim that is limited to an evaluation of
23reimbursement levels, veracity of documentation, accuracy of
24coding, or adjudication for payment.
25    "Utilization review" has the meaning provided by the
26Managed Care Reform and Patient Rights Act.

 

 

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1    "Utilization review organization" means a utilization
2review program as defined in the Managed Care Reform and
3Patient Rights Act.
4(Source: P.A. 96-857, eff. 7-1-10.)
 
5    (215 ILCS 180/20)
6    Sec. 20. Notice of right to external review.
7    (a) At the same time the health carrier sends written
8notice of a covered person's right to appeal a coverage
9decision upon an adverse determination or a final adverse
10determination as provided by the Managed Care Reform and
11Patient Rights Act, a health carrier shall notify a covered
12person, the covered person's authorized representative, if
13any, and a covered person's health care provider in writing of
14the covered person's right to request an external review as
15provided by this Act. The written notice required shall include
16the following, or substantially equivalent, language: "We have
17denied your request for the provision of or payment for a
18health care service or course of treatment. You have the right
19to have our decision reviewed by an independent review
20organization not associated with us if our decision involved
21making a judgment as to the medical necessity, appropriateness,
22health care setting, level of care, or effectiveness of the
23health care service or treatment you requested by submitting a
24written request for an external review to the Department of
25Insurance, Office of Consumer Health Information, 320 West

 

 

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1Washington Street, 4th Floor, Springfield, Illinois, 62767."
2us. Upon receipt of your request an independent review
3organization registered with the Department of Insurance will
4be assigned to review our decision.
5    (a-5) The Department may prescribe the form and content of
6the notice required under this Section.
7    (b) This subsection (b) shall apply to an expedited review
8prior to a final adverse determination. In addition to the
9notice required in subsection (a), for the health carrier shall
10include a notice related to an adverse determination, the
11health carrier shall include a statement informing the covered
12person of all of the following:
13        (1) If the covered person has a medical condition where
14    the timeframe for completion of (A) an expedited internal
15    review of an appeal a grievance involving an adverse
16    determination, (B) a final adverse determination as set
17    forth in the Managed Care Reform and Patient Rights Act, or
18    (C) a standard external review as established in this Act,
19    would seriously jeopardize the life or health of the
20    covered person or would jeopardize the covered person's
21    ability to regain maximum function, then the covered person
22    or the covered person's authorized representative may file
23    a request for an expedited external review.
24        (2) The covered person or the covered person's
25    authorized representative may file an appeal under the
26    health carrier's internal appeal process, but if the health

 

 

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1    carrier has not issued a written decision to the covered
2    person or the covered person's authorized representative
3    30 days following the date the covered person or the
4    covered person's authorized representative files an appeal
5    of an adverse determination that involves a concurrent or
6    prospective review request or 60 days following the date
7    the covered person or the covered person's authorized
8    representative files an appeal of an adverse determination
9    that involves a retrospective review request with the
10    health carrier and the covered person or the covered
11    person's authorized representative has not requested or
12    agreed to a delay, then the covered person or the covered
13    person's authorized representative may file a request for
14    external review and shall be considered to have exhausted
15    the health carrier's internal appeal process for purposes
16    of this Act. The covered person or the covered person's
17    authorized representative may file a request for an
18    expedited external review at the same time the covered
19    person or the covered person's authorized representative
20    files a request for an expedited internal appeal involving
21    an adverse determination as set forth in the Managed Care
22    Reform and Patient Rights Act if the adverse determination
23    involves a denial of coverage based on a determination that
24    the recommended or requested health care service or
25    treatment is experimental or investigational and the
26    covered person's health care provider certifies in writing

 

 

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

 

 

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1    less effective if not promptly initiated, then the covered
2    person or the covered person's authorized representative
3    may request an expedited external review at the same time
4    the covered person or the covered person's authorized
5    representative files a request for an expedited internal
6    appeal involving an adverse determination. The independent
7    review organization assigned to conduct the expedited
8    external review shall determine whether the covered person
9    is required to complete the expedited review of the appeal
10    prior to conducting the expedited external review.
11    (c) This subsection (c) shall apply to an expedited review
12upon final adverse determination. In addition to the notice
13required in subsection (a), for the health carrier shall
14include a notice related to a final adverse determination, the
15health carrier shall include a statement informing the covered
16person of all of the following:
17        (1) if the covered person has a medical condition where
18    the timeframe for completion of a standard external review
19    would seriously jeopardize the life or health of the
20    covered person or would jeopardize the covered person's
21    ability to regain maximum function, then the covered person
22    or the covered person's authorized representative may file
23    a request for an expedited external review; or
24        (2) if a final adverse determination concerns an
25    admission, availability of care, continued stay, or health
26    care service for which the covered person received

 

 

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1    emergency services, but has not been discharged from a
2    facility, then the covered person, or the covered person's
3    authorized representative, may request an expedited
4    external review; or
5        (3) if a final adverse determination concerns a denial
6    of coverage based on a determination that the recommended
7    or requested health care service or treatment is
8    experimental or investigational, and the covered person's
9    health care provider certifies in writing that the
10    recommended or requested health care service or treatment
11    that is the subject of the request would be significantly
12    less effective if not promptly initiated, then the covered
13    person or the covered person's authorized representative
14    may request an expedited external review.
15    (d) In addition to the information to be provided pursuant
16to subsections (a), (b), and (c) of this Section, the health
17carrier shall include a copy of the description of both the
18required standard and expedited external review procedures.
19The description shall highlight the external review procedures
20that give the covered person or the covered person's authorized
21representative the opportunity to submit additional
22information, including any forms used to process an external
23review.
24    (e) As part of any forms provided under subsection (d) of
25this Section, the health carrier shall include an authorization
26form, or other document approved by the Director, by which the

 

 

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1covered person, for purposes of conducting an external review
2under this Act, authorizes the health carrier and the covered
3person's treating health care provider to disclose protected
4health information, including medical records, concerning the
5covered person that is pertinent to the external review, as
6provided in the Illinois Insurance Code.
7(Source: P.A. 96-857, eff. 7-1-10.)
 
8    (215 ILCS 180/25)
9    Sec. 25. Request for external review. A covered person or
10the covered person's authorized representative may make a
11request for a standard external or expedited external review of
12an adverse determination or final adverse determination.
13Except as set forth in Sections 40 and 42 of this Act, all
14requests for external review Requests under this Section shall
15be made in writing to the Director directly to the health
16carrier that made the adverse or final adverse determination.
17All requests for external review shall be in writing except for
18requests for expedited external reviews which may me made
19orally. Health carriers must provide covered persons with forms
20to request external reviews.
21(Source: P.A. 96-857, eff. 7-1-10.)
 
22    (215 ILCS 180/30)
23    Sec. 30. Exhaustion of internal appeal grievance process.
24    (a) Except as provided in subsection (b) of this Section

 

 

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120, a request for an external review shall not be made until
2the covered person has exhausted the health carrier's internal
3appeal grievance process as set forth in the Managed Care
4Reform and Patient Rights Act.
5    (b) A covered person shall also be considered to have
6exhausted the health carrier's internal appeal grievance
7process for purposes of this Section if:
8        (1) the covered person or the covered person's
9    authorized representative has filed an appeal under the
10    health carrier's internal appeal process a request for an
11    internal review of an adverse determination pursuant to the
12    Managed Care Reform and Patient Rights Act and has not
13    received a written decision on the appeal 30 days following
14    the date the covered person or the covered person's
15    authorized representative files an appeal of an adverse
16    determination that involves a concurrent or prospective
17    review request or 60 days following the date the covered
18    person or the covered person's authorized representative
19    files an appeal of an adverse determination that involves a
20    retrospective review request request from the health
21    carrier within 15 days after receipt of the required
22    information but not more than 30 days after the request was
23    filed by the covered person or the covered person's
24    authorized representative, except to the extent the
25    covered person or the covered person's authorized
26    representative requested or agreed to a delay; however, a

 

 

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1    covered person or the covered person's authorized
2    representative may not make a request for an external
3    review of an adverse determination involving a
4    retrospective review determination until the covered
5    person has exhausted the health carrier's internal
6    grievance process;
7        (2) the covered person or the covered person's
8    authorized representative filed a request for an expedited
9    internal review of an adverse determination pursuant to the
10    Managed Care Reform and Patient Rights Act and has not
11    received a decision on such request from the health carrier
12    within 48 hours, except to the extent the covered person or
13    the covered person's authorized representative requested
14    or agreed to a delay; or
15        (3) the health carrier agrees to waive the exhaustion
16    requirement; .
17        (4) the covered person has a medical condition in which
18    the timeframe for completion of (A) an expedited internal
19    review of an appeal involving an adverse determination, (B)
20    a final adverse determination, or (C) a standard external
21    review as established in this Act would seriously
22    jeopardize the life or health of the covered person or
23    would jeopardize the covered person's ability to regain
24    maximum function;
25        (5) an adverse determination concerns a denial of
26    coverage based on a determination that the recommended or

 

 

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1    requested health care service or treatment is experimental
2    or investigational and the covered person's health care
3    provider certifies in writing that the recommended or
4    requested health care service or treatment that is the
5    subject of the request would be significantly less
6    effective if not promptly initiated; in such cases, the
7    covered person or the covered person's authorized
8    representative may request an expedited external review at
9    the same time the covered person or the covered person's
10    authorized representative files a request for an expedited
11    internal appeal involving an adverse determination; the
12    independent review organization assigned to conduct the
13    expedited external review shall determine whether the
14    covered person is required to complete the expedited review
15    of the appeal prior to conducting the expedited external
16    review; or
17        (6) the health carrier has failed to comply with
18    applicable State and federal law governing internal claims
19    and appeals procedures.
20(Source: P.A. 96-857, eff. 7-1-10.)
 
21    (215 ILCS 180/35)
22    Sec. 35. Standard external review.
23    (a) Within 4 months after the date of receipt of a notice
24of an adverse determination or final adverse determination, a
25covered person or the covered person's authorized

 

 

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1representative may file a request for an external review with
2the Director. Within one business day after the date of receipt
3of a request for external review, the Director shall send a
4copy of the request to the health carrier.
5    (b) Within 5 business days following the date of receipt of
6the external review request, the health carrier shall complete
7a preliminary review of the request to determine whether:
8        (1) the individual is or was a covered person in the
9    health benefit plan at the time the health care service was
10    requested or at the time the health care service was
11    provided;
12        (2) the health care service that is the subject of the
13    adverse determination or the final adverse determination
14    is a covered service under the covered person's health
15    benefit plan, but the health carrier has determined that
16    the health care service is not covered because it does not
17    meet the health carrier's requirements for medical
18    necessity, appropriateness, health care setting, level of
19    care, or effectiveness;
20        (3) the covered person has exhausted the health
21    carrier's internal appeal grievance process unless the
22    covered person is not required to exhaust the health
23    carrier's internal appeal process pursuant to as set forth
24    in this Act;
25        (4) (blank); and for appeals relating to a
26    determination based on treatment being experimental or

 

 

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1    investigational, the requested health care service or
2    treatment that is the subject of the adverse determination
3    or final adverse determination is a covered benefit under
4    the covered person's health benefit plan except for the
5    health carrier's determination that the service or
6    treatment is experimental or investigational for a
7    particular medical condition and is not explicitly listed
8    as an excluded benefit under the covered person's health
9    benefit plan with the health carrier and that the covered
10    person's health care provider, who ordered or provided the
11    services in question and who is licensed under the Medical
12    Practice Act of 1987, has certified that one of the
13    following situations is applicable:
14            (A) standard health care services or treatments
15        have not been effective in improving the condition of
16        the covered person;
17            (B) standard health care services or treatments
18        are not medically appropriate for the covered person;
19            (C) there is no available standard health care
20        service or treatment covered by the health carrier that
21        is more beneficial than the recommended or requested
22        health care service or treatment;
23            (D) the health care service or treatment is likely
24        to be more beneficial to the covered person, in the
25        health care provider's opinion, than any available
26        standard health care services or treatments; or

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1    determination that the health care service or treatment
2    recommended or requested is experimental or
3    investigational, whether and to what extent:
4            (A) the recommended or requested health care
5        service or treatment has been approved by the federal
6        Food and Drug Administration, if applicable, for the
7        condition;
8            (B) medical or scientific evidence or
9        evidence-based standards demonstrate that the expected
10        benefits of the recommended or requested health care
11        service or treatment is more likely than not to be
12        beneficial to the covered person than any available
13        standard health care service or treatment and the
14        adverse risks of the recommended or requested health
15        care service or treatment would not be substantially
16        increased over those of available standard health care
17        services or treatments; or
18            (C) the terms of coverage under the covered
19        person's health benefit plan with the health carrier to
20        ensure that the health care service or treatment that
21        is the subject of the opinion is experimental or
22        investigational would otherwise be covered under the
23        terms of coverage of the covered person's health
24        benefit plan with the health carrier.
25    (j) Within 5 days after the date of receipt of all
26necessary information, but in no event more than 45 days after

 

 

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

 

 

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1        evidence-based standards that were a basis for its
2        decision; and .
3            (G) the rationale for its decision.
4        (2) (Blank). For reviews of experimental or
5    investigational treatments, the notice shall include the
6    following information:
7            (A) a description of the covered person's medical
8        condition;
9            (B) a description of the indicators relevant to
10        whether there is sufficient evidence to demonstrate
11        that the recommended or requested health care service
12        or treatment is more likely than not to be more
13        beneficial to the covered person than any available
14        standard health care services or treatments 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;
19            (C) a description and analysis of any medical or
20        scientific evidence considered in reaching the
21        opinion;
22            (D) a description and analysis of any
23        evidence-based standards;
24            (E) whether the recommended or requested health
25        care service or treatment has been approved by the
26        federal Food and Drug Administration, for the

 

 

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1        condition;
2            (F) whether medical or scientific evidence or
3        evidence-based standards demonstrate that the expected
4        benefits of the recommended or requested health care
5        service or treatment is more likely than not to be more
6        beneficial to the covered person than any available
7        standard health care service or treatment and the
8        adverse risks of the recommended or requested health
9        care service or treatment would not be substantially
10        increased over those of available standard health care
11        services or treatments; and
12            (G) the written opinion of the clinical reviewer,
13        including the reviewer's recommendation as to whether
14        the recommended or requested health care service or
15        treatment should be covered and the rationale for the
16        reviewer's recommendation.
17        (3) (Blank). In reaching a decision, the assigned
18    independent review organization is not bound by any
19    decisions or conclusions reached during the health
20    carrier's utilization review process or the health
21    carrier's internal grievance or appeals process.
22        (4) Upon receipt of a notice of a decision reversing
23    the adverse determination or final adverse determination,
24    the health carrier immediately shall approve the coverage
25    that was the subject of the adverse determination or final
26    adverse determination.

 

 

HB0224 Enrolled- 33 -LRB097 05693 RPM 45756 b

1(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)
 
2    (215 ILCS 180/40)
3    Sec. 40. Expedited external review.
4    (a) A covered person or a covered person's authorized
5representative may file a request for an expedited external
6review with the Director health carrier either orally or in
7writing:
8        (1) immediately after the date of receipt of a notice
9    prior to a final adverse determination as provided by
10    subsection (b) of Section 20 of this Act;
11        (2) immediately after the date of receipt of a notice
12    upon a final adverse determination as provided by
13    subsection (c) of Section 20 of this Act; or
14        (3) if a health carrier fails to provide a decision on
15    request for an expedited internal appeal within 48 hours as
16    provided by item (2) of Section 30 of this Act.
17    (b) Upon receipt of a request for an expedited external
18review, the Director shall immediately send a copy of the
19request to the health carrier. Immediately upon receipt of the
20request for an expedited external review as provided under
21subsections (b) and (c) of Section 20, the health carrier shall
22determine whether the request meets the reviewability
23requirements set forth in items (1), (2), and (4) of subsection
24(b) of Section 35. In such cases, the following provisions
25shall apply:

 

 

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

 

 

HB0224 Enrolled- 35 -LRB097 05693 RPM 45756 b

1reviewability requirements, determining that a request meets
2the requirements of subsections (b) and (c) of Section 20, the
3Director health carrier shall immediately assign an
4independent review organization from the list of approved
5independent review organizations compiled and maintained by
6the Director to conduct the expedited review. In such cases,
7the following provisions shall apply:
8        (1) The assignment of an approved independent review
9    organization to conduct an external review in accordance
10    with this Section shall be made from those approved
11    independent review organizations qualified to conduct
12    external review as required by Sections 50 and 55 of this
13    Act.
14        (2) The Director shall immediately notify the health
15    carrier of the name of the assigned independent review
16    organization. Immediately upon receipt from the Director
17    of the name of the independent review organization assigned
18    to conduct the external review assigning an independent
19    review organization to perform an expedited external
20    review, but in no case more than 24 hours after receiving
21    such notice assigning the independent review organization,
22    the health carrier or its designee utilization review
23    organization shall provide or transmit all necessary
24    documents and information considered in making the adverse
25    determination or final adverse determination to the
26    assigned independent review organization electronically or

 

 

HB0224 Enrolled- 36 -LRB097 05693 RPM 45756 b

1    by telephone or facsimile or any other available
2    expeditious method.
3        (3) If the health carrier or its utilization review
4    organization fails to provide the documents and
5    information within the specified timeframe, the assigned
6    independent review organization may terminate the external
7    review and make a decision to reverse the adverse
8    determination or final adverse determination.
9        (4) Within one business day after making the decision
10    to terminate the external review and make a decision to
11    reverse the adverse determination or final adverse
12    determination under item (3) of this subsection (c), the
13    independent review organization shall notify the Director,
14    the health carrier, the covered person, and, if applicable,
15    the covered person's authorized representative of its
16    decision to reverse the adverse determination or final
17    adverse determination.
18    (d) In addition to the documents and information provided
19by the health carrier or its utilization review organization
20and any documents and information provided by the covered
21person and the covered person's authorized representative, the
22independent review organization, to the extent the information
23or documents are available and the independent review
24organization considers them appropriate, shall consider
25information as required by subsection (i) of Section 35 of this
26Act in reaching a decision.

 

 

HB0224 Enrolled- 37 -LRB097 05693 RPM 45756 b

1    (e) As expeditiously as the covered person's medical
2condition or circumstances requires, but in no event more than
372 hours after the date of receipt of the request for an
4expedited external review 2 business days after the receipt of
5all pertinent information, the assigned independent review
6organization shall:
7        (1) make a decision to uphold or reverse the final
8    adverse determination; and
9        (2) notify the Director, the health carrier, the
10    covered person, the covered person's health care provider,
11    and, if applicable, the covered person's authorized
12    representative, of the decision.
13    (f) In reaching a decision, the assigned independent review
14organization is not bound by any decisions or conclusions
15reached during the health carrier's utilization review process
16or the health carrier's internal appeal grievance process as
17set forth in the Managed Care Reform and Patient Rights Act.
18    (g) Upon receipt of notice of a decision reversing the
19adverse determination or final adverse determination, the
20health carrier shall immediately approve the coverage that was
21the subject of the adverse determination or final adverse
22determination.
23    (h) If the notice provided pursuant to subsection (e) of
24this Section was not in writing, then within Within 48 hours
25after the date of providing that the notice required in item
26(2) of subsection (e), the assigned independent review

 

 

HB0224 Enrolled- 38 -LRB097 05693 RPM 45756 b

1organization shall provide written confirmation of the
2decision to the Director, the health carrier, the covered
3person, and, if applicable, the covered person's authorized
4representative including the information set forth in
5subsection (j) of Section 35 of this Act as applicable.
6    (i) An expedited external review may not be provided for
7retrospective adverse or final adverse determinations.
8    (j) The assignment by the Director of an approved
9independent review organization to conduct an external review
10in accordance with this Section shall be done on a random basis
11among those independent review organizations approved by the
12Director pursuant to this Act.
13(Source: P.A. 96-857, eff. 7-1-10; revised 9-16-10.)
 
14    (215 ILCS 180/42 new)
15    Sec. 42. External review of experimental or
16investigational treatment adverse determinations.
17    (a) Within 4 months after the date of receipt of a notice
18of an adverse determination or final adverse determination that
19involves a denial of coverage based on a determination that the
20health care service or treatment recommended or requested is
21experimental or investigational, a covered person or the
22covered person's authorized representative may file a request
23for an external review with the Director.
24    (b) The following provisions apply to cases concerning
25expedited external reviews:

 

 

HB0224 Enrolled- 39 -LRB097 05693 RPM 45756 b

1        (1) A covered person or the covered person's authorized
2    representative may make an oral request for an expedited
3    external review of the adverse determination or final
4    adverse determination pursuant to subsection (a) of this
5    Section if the covered person's treating physician
6    certifies, in writing, that the recommended or requested
7    health care service or treatment that is the subject of the
8    request would be significantly less effective if not
9    promptly initiated.
10        (2) Upon receipt of a request for an expedited external
11    review, the Director shall immediately notify the health
12    carrier.
13        (3) The following provisions apply concerning notice:
14            (A) Upon notice of the request for an expedited
15        external review, the health carrier shall immediately
16        determine whether the request meets the reviewability
17        requirements of subsection (d) of this Section. The
18        health carrier shall immediately notify the Director
19        and the covered person and, if applicable, the covered
20        person's authorized representative of its eligibility
21        determination.
22            (B) The Director may specify the form for the
23        health carrier's notice of initial determination under
24        subdivision (A) of this item (3) and any supporting
25        information to be included in the notice.
26            (C) The notice of initial determination under

 

 

HB0224 Enrolled- 40 -LRB097 05693 RPM 45756 b

1        subdivision (A) of this item (3) shall include a
2        statement informing the covered person and, if
3        applicable, the covered person's authorized
4        representative that a health carrier's initial
5        determination that the external review request is
6        ineligible for review may be appealed to the Director.
7        (4) The following provisions apply concerning the
8    Director's determination:
9            (A) The Director may determine that a request is
10        eligible for external review under subsection (d) of
11        this Section notwithstanding a health carrier's
12        initial determination that the request is ineligible
13        and require that it be referred for external review.
14            (B) In making a determination under subdivision
15        (A) of this item (4), the Director's decision shall be
16        made in accordance with the terms of the covered
17        person's health benefit plan, unless such terms are
18        inconsistent with applicable law, and shall be subject
19        to all applicable provisions of this Act.
20        (5) Upon receipt of the notice that the expedited
21    external review request meets the reviewability
22    requirements of subsection (d) of this Section, the
23    Director shall immediately assign an independent review
24    organization to review the expedited request from the list
25    of approved independent review organizations compiled and
26    maintained by the Director and notify the health carrier of

 

 

HB0224 Enrolled- 41 -LRB097 05693 RPM 45756 b

1    the name of the assigned independent review organization.
2        (6) At the time the health carrier receives the notice
3    of the assigned independent review organization, the
4    health carrier or its designee utilization review
5    organization shall provide or transmit all necessary
6    documents and information considered in making the adverse
7    determination or final adverse determination to the
8    assigned independent review organization electronically or
9    by telephone or facsimile or any other available
10    expeditious method.
11    (c) Except for a request for an expedited external review
12made pursuant to subsection (b) of this Section, within one
13business day after the date of receipt of a request for
14external review, the Director shall send a copy of the request
15to the health carrier.
16    (d) Within 5 business days following the date of receipt of
17the external review request, the health carrier shall complete
18a preliminary review of the request to determine whether:
19        (1) the individual is or was a covered person in the
20    health benefit plan at the time the health care service was
21    recommended or requested or, in the case of a retrospective
22    review, at the time the health care service was provided;
23        (2) the recommended or requested health care service or
24    treatment that is the subject of the adverse determination
25    or final adverse determination is a covered benefit under
26    the covered person's health benefit plan except for the

 

 

HB0224 Enrolled- 42 -LRB097 05693 RPM 45756 b

1    health carrier's determination that the service or
2    treatment is experimental or investigational for a
3    particular medical condition and is not explicitly listed
4    as an excluded benefit under the covered person's health
5    benefit plan with the health carrier;
6        (3) the covered person's health care provider has
7    certified that one of the following situations is
8    applicable:
9            (A) standard health care services or treatments
10        have not been effective in improving the condition of
11        the covered person;
12            (B) standard health care services or treatments
13        are not medically appropriate for the covered person;
14        or
15            (C) there is no available standard health care
16        service or treatment covered by the health carrier that
17        is more beneficial than the recommended or requested
18        health care service or treatment;
19        (4) the covered person's health care provider:
20            (A) has recommended a health care service or
21        treatment that the physician certifies, in writing, is
22        likely to be more beneficial to the covered person, in
23        the physician's opinion, than any available standard
24        health care services or treatments; or
25            (B) who is a licensed, board certified or board
26        eligible physician qualified to practice in the area of

 

 

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

 

 

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

 

 

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

 

 

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1business days following the date of receipt of the notice
2provided pursuant to item (2) of this subsection (g), submit in
3writing to the assigned independent review organization
4additional information that the independent review
5organization shall consider when conducting the external
6review. The independent review organization is not required to,
7but may, accept and consider additional information submitted
8after 5 business days.
9    (h) The following provisions apply concerning assignments
10and clinical reviews:
11        (1) Within one business day after the receipt of the
12    notice of assignment to conduct the external review
13    pursuant to subsection (g) of this Section, the assigned
14    independent review organization shall select one or more
15    clinical reviewers, as it determines is appropriate,
16    pursuant to item (2) of this subsection (h) to conduct the
17    external review.
18        (2) The provisions of this item (2) apply concerning
19    the selection of reviewers:
20            (A) In selecting clinical reviewers pursuant to
21        item (1) of this subsection (h), the assigned
22        independent review organization shall select
23        physicians or other health care professionals who meet
24        the minimum qualifications described in Section 55 of
25        this Act and, through clinical experience in the past 3
26        years, are experts in the treatment of the covered

 

 

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1        person's condition and knowledgeable about the
2        recommended or requested health care service or
3        treatment.
4            (B) Neither the covered person, the covered
5        person's authorized representative, if applicable, nor
6        the health carrier shall choose or control the choice
7        of the physicians or other health care professionals to
8        be selected to conduct the external review.
9        (3) In accordance with subsection (l) of this Section,
10    each clinical reviewer shall provide a written opinion to
11    the assigned independent review organization on whether
12    the recommended or requested health care service or
13    treatment should be covered.
14        (4) In reaching an opinion, clinical reviewers are not
15    bound by any decisions or conclusions reached during the
16    health carrier's utilization review process or the health
17    carrier's internal appeal process.
18    (i) Within 5 business days after the date of receipt of the
19notice provided pursuant to subsection (g) of this Section, the
20health carrier or its designee utilization review organization
21shall provide to the assigned independent review organization
22the documents and any information considered in making the
23adverse determination or final adverse determination; in such
24cases, the following provisions shall apply:
25        (1) Except as provided in item (2) of this subsection
26    (i), failure by the health carrier or its utilization

 

 

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

 

 

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

 

 

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1        health carrier has made a decision to reverse its
2        adverse determination or final adverse determination,
3        the assigned independent review organization shall
4        terminate the external review.
5    (l) The following provisions apply concerning clinical
6review opinions:
7        (1) Except as provided in item (3) of this subsection
8    (l), within 20 days after being selected in accordance with
9    subsection (h) of this Section to conduct the external
10    review, each clinical reviewer shall provide an opinion to
11    the assigned independent review organization on whether
12    the recommended or requested health care service or
13    treatment should be covered.
14        (2) Except for an opinion provided pursuant to item (3)
15    of this subsection (l), each clinical reviewer's opinion
16    shall be in writing and include the following information:
17            (A) a description of the covered person's medical
18        condition;
19            (B) a description of the indicators relevant to
20        determining whether there is sufficient evidence to
21        demonstrate that the recommended or requested health
22        care service or treatment is more likely than not to be
23        beneficial to the covered person than any available
24        standard health care services or treatments and the
25        adverse risks of the recommended or requested health
26        care service or treatment would not be substantially

 

 

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1        increased over those of available standard health care
2        services or treatments;
3            (C) a description and analysis of any medical or
4        scientific evidence considered in reaching the
5        opinion;
6            (D) a description and analysis of any
7        evidence-based standard; and
8            (E) information on whether the reviewer's
9        rationale for the opinion is based on clause (A) or (B)
10        of item (5) of subsection (m) of this Section.
11        (3) The provisions of this item (3) apply concerning
12    the timing of opinions:
13            (A) For an expedited external review, each
14        clinical reviewer shall provide an opinion orally or in
15        writing to the assigned independent review
16        organization as expeditiously as the covered person's
17        medical condition or circumstances requires, but in no
18        event more than 5 calendar days after being selected in
19        accordance with subsection (h) of this Section.
20            (B) If the opinion provided pursuant to
21        subdivision (A) of this item (3) was not in writing,
22        then within 48 hours following the date the opinion was
23        provided, the clinical reviewer shall provide written
24        confirmation of the opinion to the assigned
25        independent review organization and include the
26        information required under item (2) of this subsection

 

 

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1        (l).
2    (m) In addition to the documents and information provided
3by the health carrier or its utilization review organization
4and the covered person and the covered person's authorized
5representative, if any, each clinical reviewer selected
6pursuant to subsection (h) of this Section, to the extent the
7information or documents are available and the clinical
8reviewer considers appropriate, shall consider the following
9in reaching a decision:
10        (1) the covered person's pertinent medical records;
11        (2) the covered person's health care provider's
12    recommendation;
13        (3) consulting reports from appropriate health care
14    providers and other documents submitted by the health
15    carrier or its designee utilization review organization,
16    the covered person, the covered person's authorized
17    representative, or the covered person's treating physician
18    or health care professional;
19        (4) the terms of coverage under the covered person's
20    health benefit plan with the health carrier to ensure that,
21    but for the health carrier's determination that the
22    recommended or requested health care service or treatment
23    that is the subject of the opinion is experimental or
24    investigational, the reviewer's opinion is not contrary to
25    the terms of coverage under the covered person's health
26    benefit plan with the health carrier; and

 

 

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1        (5) whether (A) the recommended or requested health
2    care service or treatment has been approved by the federal
3    Food and Drug Administration, if applicable, for the
4    condition or (B) medical or scientific evidence or
5    evidence-based standards demonstrate that the expected
6    benefits of the recommended or requested health care
7    service or treatment is more likely than not to be
8    beneficial to the covered person than any available
9    standard health care service or treatment and the adverse
10    risks of the recommended or requested health care service
11    or treatment would not be substantially increased over
12    those of available standard health care services or
13    treatments.
14    (n) The following provisions apply concerning decisions,
15notices, and recommendations:
16        (1) The provisions of this item (1) apply concerning
17    decisions and notices:
18            (A) Except as provided in subdivision (B) of this
19        item (1), within 20 days after the date it receives the
20        opinion of each clinical reviewer, the assigned
21        independent review organization, in accordance with
22        item (2) of this subsection (n), shall make a decision
23        and provide written notice of the decision to the
24        Director, the health carrier, the covered person, and
25        the covered person's authorized representative, if
26        applicable.

 

 

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

 

 

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

 

 

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1        (1) a general description of the reason for the request
2    for external review;
3        (2) the written opinion of each clinical reviewer,
4    including the recommendation of each clinical reviewer as
5    to whether the recommended or requested health care service
6    or treatment should be covered and the rationale for the
7    reviewer's recommendation;
8        (3) the date the independent review organization
9    received the assignment from the Director to conduct the
10    external review;
11        (4) the time period during which the external review
12    was conducted;
13        (5) the date of its decision;
14        (6) the principal reason or reasons for its decision;
15    and
16        (7) the rationale for its decision.
17    (p) Upon receipt of a notice of a decision reversing the
18adverse determination or final adverse determination, the
19health carrier shall immediately approve the coverage that was
20the subject of the adverse determination or final adverse
21determination.
22    (q) The assignment by the Director of an approved
23independent review organization to conduct an external review
24in accordance with this Section shall be done on a random basis
25among those independent review organizations approved by the
26Director pursuant to this Act.
 

 

 

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1    (215 ILCS 180/55)
2    Sec. 55. Minimum qualifications for independent review
3organizations.
4    (a) To be approved to conduct external reviews, an
5independent review organization shall have and maintain
6written policies and procedures that govern all aspects of both
7the standard external review process and the expedited external
8review process set forth in this Act that include, at a
9minimum:
10        (1) a quality assurance mechanism that ensures that:
11            (A) external reviews are conducted within the
12        specified timeframes and required notices are provided
13        in a timely manner;
14            (B) selection of qualified and impartial clinical
15        reviewers to conduct external reviews on behalf of the
16        independent review organization and suitable matching
17        of reviewers to specific cases and that the independent
18        review organization employs or contracts with an
19        adequate number of clinical reviewers to meet this
20        objective;
21            (C) for adverse determinations involving
22        experimental or investigational treatments, in
23        assigning clinical reviewers, the independent review
24        organization selects physicians or other health care
25        professionals who, through clinical experience in the

 

 

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1        past 3 years, are experts in the treatment of the
2        covered person's condition and knowledgeable about the
3        recommended or requested health care service or
4        treatment;
5            (D) the health carrier, the covered person, and the
6        covered person's authorized representative shall not
7        choose or control the choice of the physicians or other
8        health care professionals to be selected to conduct the
9        external review;
10            (E) confidentiality of medical and treatment
11        records and clinical review criteria; and
12            (F) any person employed by or under contract with
13        the independent review organization adheres to the
14        requirements of this Act;
15        (2) a toll-free telephone service operating on a
16    24-hour-day, 7-day-a-week basis that accepts, receives,
17    and records information related to external reviews and
18    provides appropriate instructions; and
19        (3) an agreement to maintain and provide to the
20    Director the information set out in Section 70 of this Act.
21    (b) All clinical reviewers assigned by an independent
22review organization to conduct external reviews shall be
23physicians or other appropriate health care providers who meet
24the following minimum qualifications:
25        (1) be an expert in the treatment of the covered
26    person's medical condition that is the subject of the

 

 

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1    external review;
2        (2) be knowledgeable about the recommended health care
3    service or treatment through recent or current actual
4    clinical experience treating patients with the same or
5    similar medical condition of the covered person;
6        (3) hold a non-restricted license in a state of the
7    United States and, for physicians, a current certification
8    by a recognized American medical specialty board in the
9    area or areas appropriate to the subject of the external
10    review; and
11        (4) have no history of disciplinary actions or
12    sanctions, including loss of staff privileges or
13    participation restrictions, that have been taken or are
14    pending by any hospital, governmental agency or unit, or
15    regulatory body that raise a substantial question as to the
16    clinical reviewer's physical, mental, or professional
17    competence or moral character.
18    (c) In addition to the requirements set forth in subsection
19(a), an independent review organization may not own or control,
20be a subsidiary of, or in any way be owned, or controlled by,
21or exercise control with a health benefit plan, a national,
22State, or local trade association of health benefit plans, or a
23national, State, or local trade association of health care
24providers.
25    (d) Conflicts of interest prohibited. In addition to the
26requirements set forth in subsections (a), (b), and (c) of this

 

 

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1Section, to be approved pursuant to this Act to conduct an
2external review of a specified case, neither the independent
3review organization selected to conduct the external review nor
4any clinical reviewer assigned by the independent organization
5to conduct the external review may have a material
6professional, familial or financial conflict of interest with
7any of the following:
8        (1) the health carrier that is the subject of the
9    external review;
10        (2) the covered person whose treatment is the subject
11    of the external review or the covered person's authorized
12    representative;
13        (3) any officer, director or management employee of the
14    health carrier that is the subject of the external review;
15        (4) the health care provider, the health care
16    provider's medical group or independent practice
17    association recommending the health care service or
18    treatment that is the subject of the external review;
19        (5) the facility at which the recommended health care
20    service or treatment would be provided; or
21        (6) the developer or manufacturer of the principal
22    drug, device, procedure, or other therapy being
23    recommended for the covered person whose treatment is the
24    subject of the external review.
25    (e) An independent review organization that is accredited
26by a nationally recognized private accrediting entity that has

 

 

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1independent review accreditation standards that the Director
2has determined are equivalent to or exceed the minimum
3qualifications of this Section shall be presumed to be in
4compliance with this Section and shall be eligible for approval
5under this Act.
6    (f) An independent review organization shall be unbiased.
7An independent review organization shall establish and
8maintain written procedures to ensure that it is unbiased in
9addition to any other procedures required under this Section.
10    (g) Nothing in this Act precludes or shall be interpreted
11to preclude a health carrier from contracting with approved
12independent review organizations to conduct external reviews
13assigned to it from such health carrier.
14(Source: P.A. 96-857, eff. 7-1-10.)
 
15    (215 ILCS 180/65)
16    Sec. 65. External review reporting requirements.
17    (a) Each health carrier shall maintain written records in
18the aggregate, by state, and for each type of health benefit
19plan offered by the health carrier on all requests for external
20review that the health carrier received notice from the
21Director for each calendar year and submit a report to the
22Director in the format specified by the Director by March 1 of
23each year.
24    (a-5) An independent review organization assigned pursuant
25to this Act to conduct an external review shall maintain

 

 

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1written records in the aggregate by state and by health carrier
2on all requests for external review for which it conducted an
3external review during a calendar year and submit a report in
4the format specified by the Director by March 1 of each year.
5    (a-10) The report required by subsection (a-5) shall
6include in the aggregate by state, and for each health carrier:
7        (1) the total number of requests for external review;
8        (2) the number of requests for external review resolved
9    and, of those resolved, the number resolved upholding the
10    adverse determination or final adverse determination and
11    the number resolved reversing the adverse determination or
12    final adverse determination;
13        (3) the average length of time for resolution;
14        (4) a summary of the types of coverages or cases for
15    which an external review was sought, as provided in the
16    format required by the Director;
17        (5) the number of external reviews that were terminated
18    as the result of a reconsideration by the health carrier of
19    its adverse determination or final adverse determination
20    after the receipt of additional information from the
21    covered person or the covered person's authorized
22    representative; and
23        (6) any other information the Director may request or
24    require.
25    (a-15) The independent review organization shall retain
26the written records required pursuant to this Section for at

 

 

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1least 3 years.
2    (b) The report required under subsection (a) of this
3Section shall include in the aggregate, by state, and by type
4of health benefit plan:
5        (1) the total number of requests for external review;
6        (2) the total number of requests for expedited external
7    review;
8        (3) the total number of requests for external review
9    denied;
10        (4) the number of requests for external review
11    resolved, including:
12            (A) the number of requests for external review
13        resolved upholding the adverse determination or final
14        adverse determination;
15            (B) the number of requests for external review
16        resolved reversing the adverse determination or final
17        adverse determination;
18            (C) the number of requests for expedited external
19        review resolved upholding the adverse determination or
20        final adverse determination; and
21            (D) the number of requests for expedited external
22        review resolved reversing the adverse determination or
23        final adverse determination;
24        (5) the average length of time for resolution for an
25    external review;
26        (6) the average length of time for resolution for an

 

 

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1    expedited external review;
2        (7) a summary of the types of coverages or cases for
3    which an external review was sought, as specified below:
4            (A) denial of care or treatment (dissatisfaction
5        regarding prospective non-authorization of a request
6        for care or treatment recommended by a provider
7        excluding diagnostic procedures and referral requests;
8        partial approvals and care terminations are also
9        considered to be denials);
10            (B) denial of diagnostic procedure
11        (dissatisfaction regarding prospective
12        non-authorization of a request for a diagnostic
13        procedure recommended by a provider; partial approvals
14        are also considered to be denials);
15            (C) denial of referral request (dissatisfaction
16        regarding non-authorization of a request for a
17        referral to another provider recommended by a PCP);
18            (D) claims and utilization review (dissatisfaction
19        regarding the concurrent or retrospective evaluation
20        of the coverage, medical necessity, efficiency or
21        appropriateness of health care services or treatment
22        plans; prospective "Denials of care or treatment",
23        "Denials of diagnostic procedures" and "Denials of
24        referral requests" should not be classified in this
25        category, but the appropriate one above);
26        (8) the number of external reviews that were terminated

 

 

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1    as the result of a reconsideration by the health carrier of
2    its adverse determination or final adverse determination
3    after the receipt of additional information from the
4    covered person or the covered person's authorized
5    representative; and
6        (9) any other information the Director may request or
7    require.
8(Source: P.A. 96-857, eff. 7-1-10.)
 
9    (215 ILCS 180/75)
10    Sec. 75. Disclosure requirements.
11    (a) Each health carrier shall include a description of the
12external review procedures in, or attached to, the policy,
13certificate, membership booklet, and outline of coverage or
14other evidence of coverage it provides to covered persons.
15    (b) The description required under subsection (a) of this
16Section shall include a statement that informs the covered
17person of the right of the covered person to file a request for
18an external review of an adverse determination or final adverse
19determination with the Director health carrier. The statement
20shall explain that external review is available when the
21adverse determination or final adverse determination involves
22an issue of medical necessity, appropriateness, health care
23setting, level of care, or effectiveness. The statement shall
24include the toll-free telephone number and address of the
25Office of Consumer Health Insurance within the Department of

 

 

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1Insurance.
2(Source: P.A. 96-857, eff. 7-1-10.)
 
3    (215 ILCS 180/80 new)
4    Sec. 80. Administration and enforcement.
5    (a) The Director of Insurance may adopt rules necessary to
6implement the Department's responsibilities under this Act.
7    (b) The Director is authorized to make use of any of the
8powers established under the Illinois Insurance Code to enforce
9the laws of this State. This includes but is not limited to,
10the Director's administrative authority to investigate, issue
11subpoenas, conduct depositions and hearings, issue orders,
12including, without limitation, orders pursuant to Article XII
131/2 and Section 401.1 of the Illinois Insurance Code, and
14impose penalties.
 
15    Section 99. Effective date. This Act takes effect on July
161, 2011.