Statutes > Illinois Statutes > CHAPTER 215 INSURANCE > 215 ILCS 180/ Health Carrier External Review Act.

215 ILCS 180/ Health Carrier External Review Act.

    (215 ILCS 180/1)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 1. Short title. This Act may be cited as the Health Carrier External Review Act.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 180/5)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 5. Purpose and intent. The purpose of this Act is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination, as defined in this Act.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 180/10)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 10. Definitions. For the purposes of this Act:
    "Adverse determination" means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated.
    "Authorized representative" means:
        (1) a person to whom a covered person has given
     express written consent to represent the covered person in an external review, including the covered person's health care provider;
        (2) a person authorized by law to provide substituted
     consent for a covered person; or
        (3) the covered person's health care provider when
     the covered person is unable to provide consent.
    "Best evidence" means evidence based on:
        (1) randomized clinical trials;
        (2) if randomized clinical trials are not available,
     then cohort studies or case‑control studies;
        (3) if items (1) and (2) are not available, then
     case‑series; or
        (4) if items (1), (2), and (3) are not available,
     then expert opinion.
    "Case‑series" means an evaluation of a series of patients with a particular outcome, without the use of a control group.
    "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.
    "Cohort study" means a prospective evaluation of 2 groups of patients with only one group of patients receiving specific intervention.
    "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.
    "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
    "Director" means the Director of the Department of Insurance.
    "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
        (1) placing the health of the individual or, with
     respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
        (2) serious impairment to bodily functions; or
        (3) serious dysfunction of any bodily organ or part.
    "Emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition.
    "Evidence‑based standard" means the conscientious, explicit, and judicious use of the current best evidence based on an overall systematic review of the research in making decisions about the care of individual patients.
    "Expert opinion" means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy.
    "Facility" means an institution providing health care services or a health care setting.
    "Final adverse determination" means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth by the Managed Care Reform and Patient Rights Act.
    "Health benefit plan" means a policy, contract, certificate, plan, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
    "Health care provider" or "provider" means a physician, hospital facility, or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with State law, responsible for recommending health care services on behalf of a covered person.
    "Health care services" means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.
    "Health carrier" means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, or any other entity providing a plan of health insurance, health benefits, or health care services. "Health carrier" also means Limited Health Service Organizations (LHSO) and Voluntary Health Service Plans.
    "Health information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to:
        (1) the past, present, or future physical, mental, or
     behavioral health or condition of an individual or a member of the individual's family;
        (2) the provision of health care services to an
     individual; or
        (3) payment for the provision of health care services
     to an individual.
    "Independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.
    "Medical or scientific evidence" means evidence found in the following sources:
        (1) peer‑reviewed scientific studies published in or
     accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;
        (2) peer‑reviewed medical literature, including
     literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE);
        (3) medical journals recognized by the Secretary of
     Health and Human Services under Section 1861(t)(2) of the federal Social Security Act;
        (4) the following standard reference compendia:
            (a) The American Hospital Formulary Service‑Drug
         Information;
            (b) Drug Facts and Comparisons;
            (c) The American Dental Association Accepted
         Dental Therapeutics; and
            (d) The United States Pharmacopoeia‑Drug
         Information;
        (5) findings, studies, or research conducted by or
     under the auspices of federal government agencies and nationally recognized federal research institutes, including:
            (a) the federal Agency for Healthcare Research
         and Quality;
            (b) the National Institutes of Health;
            (c) the National Cancer Institute;
            (d) the National Academy of Sciences;
            (e) the Centers for Medicare & Medicaid Services;
            (f) the federal Food and Drug Administration; and
            (g) any national board recognized by the National
         Institutes of Health for the purpose of evaluating the medical value of health care services; or
        (6) any other medical or scientific evidence that is
     comparable to the sources listed in items (1) through (5).
    "Protected health information" means health information (i) that identifies an individual who is the subject of the information; or (ii) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual.
    "Retrospective review" means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.
    "Utilization review" has the meaning provided by the
     Managed Care Reform and Patient Rights Act.
    "Utilization review organization" means a utilization
     review program as defined in the Managed Care Reform and Patient Rights Act.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 180/15)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 15. Applicability and scope.
    (a) Except as provided in subsection (b) of this Section, this Act shall apply to all health carriers.
    (b) The provisions of this Act shall not apply to a policy or certificate that provides coverage only for a specified disease, specified accident or accident‑only coverage, credit, dental, disability income, hospital indemnity, long‑term care insurance as defined by Article XIXA of the Illinois Insurance Code, vision care, or any other limited supplemental benefit; a Medicare supplement policy of insurance as defined by the Director by regulation; coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program; any coverage issued under Chapter 55 of Title 10, U.S. Code and any coverage issued as supplement to that coverage; any coverage issued as supplemental to liability insurance, workers' compensation, or similar insurance; automobile medical‑payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 180/20)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 20. Notice of right to external review.
    (a) At the same time the health carrier sends written notice of a covered person's right to appeal a coverage decision upon an adverse determination or a final adverse determination as provided by the Managed Care Reform and Patient Rights Act, a health carrier shall notify a covered person and a covered person's health care provider in writing of the covered person's right to request an external review as provided by this Act. The written notice required shall include the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You have the right to have our decision reviewed by an independent review organization not associated with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested by submitting a written request for an external review to us. Upon receipt of your request an independent review organization registered with the Department of Insurance will be assigned to review our decision.
    (b) This subsection (b) shall apply to an expedited review prior to a final adverse determination. In addition to the notice required in subsection (a), the health carrier shall include a notice related to an adverse determination, a statement informing the covered person all of the following:
        (1) If the covered person has a medical condition
     where the timeframe for completion of (A) an expedited internal review of a grievance involving an adverse determination, (B) a final adverse determination as set forth in the Managed Care Reform and Patient Rights Act, or (C) a standard external review as established in this Act, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, then the covered person or the covered person's authorized representative may file a request for an expedited external review.
        (2) The covered person or the covered person's
     authorized representative may file a request for an expedited external review at the same time the covered person or the covered person's authorized representative files a request for an expedited internal appeal involving an adverse determination as set forth in the Managed Care Reform and Patient Rights Act if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's health care provider certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated. The independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited review of the grievance prior to conducting the expedited external review.
        (3) If an adverse determination concerns a denial of
     coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's health care provider certifies in writing that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, then the covered person or the covered person's authorized representative may request an expedited external review.
    (c) This subsection (c) shall apply to an expedited review upon final adverse determination. In addition to the notice required in subsection (a), the health carrier shall include a notice related to a final adverse determination, a statement informing the covered person all of the following:
        (1) if the covered person has a medical condition
     where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, then the covered person or the covered person's authorized representative may file a request for an expedited external review; or
        (2) if a final adverse determination concerns an
     admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not been discharged from a facility, then the covered person, or the covered person's authorized representative, may request an expedited external review; or
        (3) if a final adverse determination concerns a
     denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, and the covered person's health care provider certifies in writing that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, then the covered person or the covered person's authorized representative may request an expedited external review.
    (d) In addition to the information to be provided pursuant to subsections (a), (b), and (c) of this Section, the health carrier shall include a copy of the description of both the required standard and expedited external review procedures. The description shall highlight the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information, including any forms used to process an external review.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 180/25)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 25. Request for external review. A covered person or the covered person's authorized representative may make a request for a standard external or expedited external review of an adverse determination or final adverse determination. Requests under this Section shall be made directly to the health carrier that made the adverse or final adverse determination. All requests for external review shall be in writing except for requests for expedited external reviews which may me made orally. Health carriers must provide covered persons with forms to request external reviews.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 180/30)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 30. Exhaustion of internal grievance process.
    Except as provided in subsection (b) of Section 20, a request for an external review shall not be made until the covered person has exhausted the health carrier's internal grievance process as set forth in the Managed Care Reform and Patient Rights Act. A covered person shall also be considered to have exhausted the health carrier's internal grievance process for purposes of this Section if:
        (1) the covered person or the covered person's
     authorized representative filed a request for an internal review of an adverse determination pursuant to the Managed Care Reform and Patient Rights Act and has not received a written decision on the request from the health carrier within 15 days after receipt of the required information but not more than 30 days after the request was filed by the covered person or the covered person's authorized representative, except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay; however, a covered person or the covered person's authorized representative may not make a request for an external review of an adverse determination involving a retrospective review determination until the covered person has exhausted the health carrier's internal grievance process;
        (2) the covered person or the covered person's
     authorized representative filed a request for an expedited internal review of an adverse determination pursuant to the Managed Care Reform and Patient Rights Act and has not received a decision on request from the health carrier within 48 hours, except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay; or
        (3) the health carrier agrees to waive the exhaustion
     requirement.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 180/35)
    Sec. 35. Standard external review.
    (a) Within 4 months after the date of receipt of a notice of an adverse determination or final adverse determination, a covered person or the covered person's authorized representative may file a request for an external review with the health carrier.
    (b) Within 5 business days following the date of receipt of the external review request, the health carrier shall complete a preliminary review of the request to determine whether:
        (1) the individual is or was a covered person in the
    health benefit plan at the time the health care service was requested or at the time the health care service was provided;
        (2) the health care service that is the subject of
    the adverse determination or the final adverse determination is a covered service under the covered person's health benefit plan, but the health carrier has determined that the health care service is not covered because it does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness;
        (3) the covered person has exhausted the health
    carrier's internal grievance process as set forth in this Act;
        (4) for appeals relating to a determination based on
    treatment being experimental or investigational, the requested health care service or treatment that is the subject of the adverse determination or final adverse determination is a covered benefit under the covered person's health benefit plan except for the health carrier's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit under the covered person's health benefit plan with the health carrier and that the covered person's health care provider, who ordered or provided the services in question and who is licensed under the Medical Practice Act of 1987, has certified that one of the following situations is applicable:
            (A) standard health care services or treatments
        have not been effective in improving the condition of the covered person;
            (B) standard health care services or treatments
        are not medically appropriate for the covered person;
            (C) there is no available standard health care
        service or treatment covered by the health carrier that is more beneficial than the recommended or requested health care service or treatment;
            (D) the health care service or treatment is
        likely to be more beneficial to the covered person, in the health care provider's opinion, than any available standard health care services or treatments; or
            (E) that scientifically valid studies using
        accepted protocols demonstrate that the health care service or treatment requested is likely to be more beneficial to the covered person than any available standard health care services or treatments; and
        (5) the covered person has provided all the
    information and forms required to process an external review, as specified in this Act.
    (c) Within one business day after completion of the preliminary review, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative in writing whether the request is complete and eligible for external review. If the request:
        (1) is not complete, the health carrier shall inform
    the covered person and, if applicable, the covered person's authorized representative in writing and include in the notice what information or materials are required by this Act to make the request complete; or
        (2) is not eligible for external review, the health
    carrier shall inform the covered person and, if applicable, the covered person's authorized representative in writing and include in the notice the reasons for its ineligibility.
    The notice of initial determination of ineligibility
    shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the Director by filing a complaint with the Director.
    Notwithstanding a health carrier's initial determination
    that the request is ineligible for external review, the Director may determine that a request is eligible for external review and require that it be referred for external review. In making such determination, the Director's decision shall be in accordance with the terms of the covered person's health benefit plan and shall be subject to all applicable provisions of this Act.
    (d) Whenever a request is eligible for external review the health carrier shall, within 5 business days:
        (1) assign an independent review organization from
    the list of approved independent review organizations compiled and maintained by the Director; and
        (2) notify in writing the covered person and, if
    applicable, the covered person's authorized representative of the request's eligibility and acceptance for external review and the name of the independent review organization.
    The health carrier shall include in the notice provided
    to the covered person and, if applicable, the covered person's authorized representative a statement that the covered person or the covered person's authorized representative may, within 5 business days following the date of receipt of the notice provided pursuant to item (2) of this subsection (d), submit in writing to the assigned independent review organization additional information that the independent review organization shall consider when conducting the external review. The independent review organization is not required to, but may, accept and consider additional information submitted after 5 business days.
    (e) The assignment of an approved independent review organization to conduct an external review in accordance with this Section shall be made from those approved independent review organizations qualified to conduct external review as required by Sections 50 and 55 of this Act.
    (f) Upon assignment of an independent review organization, the health carrier or its designee utilization review organization shall, within 5 business days, provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination; in such cases, the following provisions shall apply:
        (1) Except as provided in item (2) of this subsection
    (f), failure by the health carrier or its utilization review organization to provide the documents and information within the specified time frame shall not delay the conduct of the external review.
        (2) If the health carrier or its utilization review
    organization fails to provide the documents and information within the specified time frame, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination.
        (3) Within one business day after making the decision
    to terminate the external review and make a decision to reverse the adverse determination or final adverse determination under item (2) of this subsection (f), the independent review organization shall notify the health carrier, the covered person and, if applicable, the covered person's authorized representative, of its decision to reverse the adverse determination.
    (g) Upon receipt of the information from the health
    carrier or its utilization review organization, the assigned independent review organization shall review all of the information and documents and any other information submitted in writing to the independent review organization by the covered person and the covered person's authorized representative.
    (h) Upon receipt of any information submitted by the
    covered person or the covered person's authorized representative, the independent review organization shall forward the information to the health carrier within 1 business day.
        (1) Upon receipt of the information, if any, the
    health carrier may reconsider its adverse determination or final adverse determination that is the subject of the external review.
        (2) Reconsideration by the health carrier of its
    adverse determination or final adverse determination shall not delay or terminate the external review.
        (3) The external review may only be terminated if the
    health carrier decides, upon completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the health care service that is the subject of the adverse determination or final adverse determination. In such cases, the following provisions shall apply:
            (A) Within one business day after making the
        decision to reverse its adverse determination or final adverse determination, the health carrier shall notify the covered person and if applicable, the covered person's authorized representative, and the assigned independent review organization in writing of its decision.
            (B) Upon notice from the health carrier that the
        health carrier has made a decision to reverse its adverse determination or final adverse determination, the assigned independent review organization shall terminate the external review.
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