Bill Text: IL HB0224 | 2011-2012 | 97th General Assembly | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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

Spectrum: Partisan Bill (Democrat 7-0)

Status: (Passed) 2011-08-26 - Public Act . . . . . . . . . 97-0574 [HB0224 Detail]

Download: Illinois-2011-HB0224-Amended.html

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Sen. Heather A. Steans

Filed: 5/10/2011

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

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effectiveness or is determined to be experimental or
investigational and the requested benefit is therefore
denied, reduced, or terminated or payment is not provided
or made, in whole or in part, for the benefit;
(2) the denial, reduction, or termination of or failure
to provide or make payment, in whole or in part, for a
benefit based on a determination by a health carrier or its
designee utilization review organization of a covered
person's eligibility to participate in the health
carrier's health benefit plan;
(3) any prospective review or retrospective review
determination that denies, reduces, or terminates or fails
to provide or make payment, in whole or in part, for a
benefit; or
(4) a rescission of coverage 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

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written consent to represent the covered person for
purposes of this Law;
(2) a person authorized by law to provide substituted
consent for a covered person;
(3) a family member of the covered person or the
covered person's treating health care professional when
the covered person is unable to provide consent;
(4) a health care provider when the covered person's
health benefit plan requires that a request for a benefit
under the plan be initiated by the health care provider; or
(5) in the case of an urgent care request, a health
care provider with knowledge of the covered person's
medical condition.
(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

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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.
"Concurrent review" means a review conducted during a
patient's stay or course of treatment in a facility, the office
of a health care professional, or other inpatient or outpatient
health care setting.
"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,

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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

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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

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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

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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

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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).
"Person" means an individual, a corporation, a
partnership, an association, a joint venture, a joint stock
company, a trust, an unincorporated organization, any similar
entity, or any combination of the foregoing.
"Prospective review" means a review conducted prior to an
admission or the provision of a health care service or a course
of treatment in accordance with a health carrier's requirement
that the health care service or course of treatment, in whole
or in part, be approved prior to its provision.
"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.
"Randomized clinical trial" means a controlled prospective
study of patients that have been randomized into an
experimental group and a control group at the beginning of the
study with only the experimental group of patients receiving a
specific intervention, which includes study of the groups for
variables and anticipated outcomes over time.
"Retrospective review" means any review of a request for a
benefit that is not a concurrent or prospective review request.
"Retrospective review" does not include the review of a claim

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that is limited to veracity of documentation or accuracy of
coding. 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 180/20)
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, the covered person's authorized representative, if
any, 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

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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 the Department of
Insurance, Office of Consumer Health Information, 320 West
Washington Street, 4th Floor, Springfield, Illinois, 62767."
us. Upon receipt of your request an independent review
organization registered with the Department of Insurance will
be assigned to review our decision.
(a-5) The Department may prescribe the form and content of
the notice required under this Section.
(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), for the health carrier shall
include a notice related to an adverse determination, the
health carrier shall include a statement informing the covered
person of 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 an appeal 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,

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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 an appeal under the
health carrier's internal appeal process, but if the health
carrier has not issued a written decision to the covered
person or the covered person's authorized representative
30 days following the date the covered person or the
covered person's authorized representative files an appeal
of an adverse determination that involves a concurrent or
prospective review request or 60 days following the date
the covered person or the covered person's authorized
representative files an appeal of an adverse determination
that involves a retrospective review request with the
health carrier and the covered person or the covered
person's authorized representative has not requested or
agreed to a delay, then the covered person or the covered
person's authorized representative may file a request for
external review and shall be considered to have exhausted
the health carrier's internal appeal process for purposes
of this Act. 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

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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 the covered person or the covered person's
authorized representative filed a request for an expedited
internal review of an adverse determination and has not
received a decision on such 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, then the covered person or the
covered person's authorized representative may file a
request for external review and shall be considered to have
exhausted the health carrier's internal appeal process for

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the purposes of this Act.
(4) (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 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. The independent
review organization assigned to conduct the expedited
external review shall determine whether the covered person
is required to complete the expedited review of the appeal
prior to conducting the 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), for the health carrier shall
include a notice related to a final adverse determination, the
health carrier shall include a statement informing the covered
person of all of the following:
(1) if the covered person has a medical condition where
the timeframe for completion of a standard external review

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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.

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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.
(e) As part of any forms provided under subsection (d) of
this Section, the health carrier shall include an authorization
form, or other document approved by the Director, by which the
covered person, for purposes of conducting an external review
under this Act, authorizes the health carrier and the covered
person's treating health care provider to disclose protected
health information, including medical records, concerning the
covered person that is pertinent to the external review, as
provided in the Illinois Insurance Code.
(Source: P.A. 96-857, eff. 7-1-10.)
(215 ILCS 180/25)
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.
Except as set forth in Sections 40 and 42 of this Act, all
requests for external review Requests under this Section shall
be made in writing to the Director directly to the health
carrier that made the adverse or final adverse determination.
All requests for external review shall be in writing except for

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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)
Sec. 30. Exhaustion of internal appeal grievance process.
(a) Except as provided in subsection (b) of this Section
20, a request for an external review shall not be made until
the covered person has exhausted the health carrier's internal
appeal grievance process as set forth in the Managed Care
Reform and Patient Rights Act.
(b) A covered person shall also be considered to have
exhausted the health carrier's internal appeal grievance
process for purposes of this Section if:
(1) the covered person or the covered person's
authorized representative has filed an appeal under the
health carrier's internal appeal process 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 appeal 30 days following
the date the covered person or the covered person's
authorized representative files an appeal of an adverse
determination that involves a prospective review request
or 60 days following the date the covered person or the
covered person's authorized representative files an appeal

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of an adverse determination that involves a retrospective
review request 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 such 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; .
(4) the covered person has a medical condition in which
the timeframe for completion of (A) an expedited internal
review of a appeal involving an adverse determination, (B)

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a final adverse determination, 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;
(5) 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; in such cases, the
covered person or the covered person's authorized
representative may request 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; the
independent review organization assigned to conduct the
expedited external review shall determine whether the
covered person is required to complete the expedited review
of the appeal prior to conducting the expedited external
review; or
(6) the health carrier has failed to comply with
applicable State and federal law governing internal claims
and appeals procedures.

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(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 Director. Within one business day after the date of receipt
of a request for external review, the Director shall send a
copy of the request to 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;

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(3) the covered person has exhausted the health
carrier's internal appeal grievance process unless the
covered person is not required to exhaust the health
carrier's internal appeal process pursuant to as set forth
in this Act;
(4) (blank); and 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

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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
Director and 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 Director and 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

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(2) is not eligible for external review, the health
carrier shall inform the Director and covered person and,
if applicable, the covered person's authorized
representative in writing and include in the notice the
reasons for its ineligibility.
The Department may specify the form for the health
carrier's notice of initial determination under this
subsection (c) and any supporting information to be included in
the notice.
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, unless such terms are inconsistent with
applicable law, and shall be subject to all applicable
provisions of this Act.
(d) Whenever the Director receives notice that a request is
eligible for external review following the preliminary review

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conducted pursuant to this Section the health carrier shall,
within one 5 business day after the date of receipt of the
notice, the Director shall days:
(1) assign an independent review organization from the
list of approved independent review organizations compiled
and maintained by the Director pursuant to this Act and
notify the health carrier of the name of the assigned
independent review organization; 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 Director 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 by the Director of an approved
independent review organization to conduct an external review

09700HB0224sam001 - 25 - LRB097 05693 RPM 55431 a
in accordance with this Section shall be done on a random basis
among those independent review organizations approved by the
Director pursuant to this Act. 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) Within Upon assignment of an independent review
organization, the health carrier or its designee utilization
review organization shall, within 5 business days after the
date of receipt of the notice provided pursuant to item (1) of
subsection (d) of this Section, the health carrier or its
designee utilization review organization shall 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

09700HB0224sam001 - 26 - LRB097 05693 RPM 55431 a
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 Director,
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.

09700HB0224sam001 - 27 - LRB097 05693 RPM 55431 a
(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 Director, 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.
(i) In addition to the documents and information provided
by the health carrier or its utilization review organization
and the covered person and the covered person's authorized
representative, if any, the independent review organization,

09700HB0224sam001 - 28 - LRB097 05693 RPM 55431 a
to the extent the information or documents are available and
the independent review organization considers them
appropriate, shall consider the following in reaching a
decision:
(1) the covered person's pertinent medical records;
(2) the covered person's health care provider's
recommendation;
(3) consulting reports from appropriate health care
providers and other documents submitted by the health
carrier or its designee utilization review organization,
the covered person, the covered person's authorized
representative, or the covered person's treating provider;
(4) the terms of coverage under the covered person's
health benefit plan with the health carrier to ensure that
the independent review organization's decision is not
contrary to the terms of coverage under the covered
person's health benefit plan with the health carrier,
unless the terms are inconsistent with applicable law;
(5) the most appropriate practice guidelines, which
shall include applicable evidence-based standards and may
include any other practice guidelines developed by the
federal government, national or professional medical
societies, boards, and associations;
(6) any applicable clinical review criteria developed
and used by the health carrier or its designee utilization
review organization; and

09700HB0224sam001 - 29 - LRB097 05693 RPM 55431 a
(7) the opinion of the independent review
organization's clinical reviewer or reviewers after
considering items (1) through (6) of this subsection (i) to
the extent the information or documents are available and
the clinical reviewer or reviewers considers the
information or documents appropriate; and
(8) (blank). for a denial of coverage based on a
determination that the health care service or treatment
recommended or requested is experimental or
investigational, whether and to what extent:
(A) the recommended or requested health care
service or treatment has been approved by the federal
Food and Drug Administration, if applicable, for the
condition;
(B) medical or scientific evidence or
evidence-based standards demonstrate that the expected
benefits of the recommended or requested health care
service or treatment is more likely than not to be
beneficial to the covered person than any available
standard health care service or treatment and the
adverse risks of the recommended or requested health
care service or treatment would not be substantially
increased over those of available standard health care
services or treatments; or
(C) the terms of coverage under the covered
person's health benefit plan with the health carrier to

09700HB0224sam001 - 30 - LRB097 05693 RPM 55431 a
ensure that the health care service or treatment that
is the subject of the opinion is experimental or
investigational would otherwise be covered under the
terms of coverage of the covered person's health
benefit plan with the health carrier.
(j) Within 5 days after the date of receipt of all
necessary information, but in no event more than 45 days after
the date of receipt of the request for an external review, the
assigned independent review organization shall provide written
notice of its decision to uphold or reverse the adverse
determination or the final adverse determination to the
Director, the health carrier, the covered person, and, if
applicable, the covered person's authorized representative. In
reaching a decision, the assigned independent review
organization is not bound by any claim determinations reached
prior to the submission of information to the independent
review organization. In such cases, the following provisions
shall apply:
(1) The independent review organization shall include
in the notice:
(A) a general description of the reason for the
request for external review;
(B) the date the independent review organization
received the assignment from the Director health
carrier to conduct the external review;
(C) the time period during which the external

09700HB0224sam001 - 31 - LRB097 05693 RPM 55431 a
review was conducted;
(D) references to the evidence or documentation,
including the evidence-based standards, considered in
reaching its decision;
(E) the date of its decision; and
(F) the principal reason or reasons for its
decision, including what applicable, if any,
evidence-based standards that were a basis for its
decision; and .
(G) the rationale for its decision.
(2) (Blank). For reviews of experimental or
investigational treatments, the notice shall include the
following information:
(A) a description of the covered person's medical
condition;
(B) a description of the indicators relevant to
whether there is sufficient evidence to demonstrate
that the recommended or requested health care service
or treatment is more likely than not to be more
beneficial to the covered person than any available
standard health care services or treatments and the
adverse risks of the recommended or requested health
care service or treatment would not be substantially
increased over those of available standard health care
services or treatments;
(C) a description and analysis of any medical or

09700HB0224sam001 - 32 - LRB097 05693 RPM 55431 a
scientific evidence considered in reaching the
opinion;
(D) a description and analysis of any
evidence-based standards;
(E) whether the recommended or requested health
care service or treatment has been approved by the
federal Food and Drug Administration, for the
condition;
(F) whether medical or scientific evidence or
evidence-based standards demonstrate that the expected
benefits of the recommended or requested health care
service or treatment is more likely than not to be more
beneficial to the covered person than any available
standard health care service or treatment and the
adverse risks of the recommended or requested health
care service or treatment would not be substantially
increased over those of available standard health care
services or treatments; and
(G) the written opinion of the clinical reviewer,
including the reviewer's recommendation as to whether
the recommended or requested health care service or
treatment should be covered and the rationale for the
reviewer's recommendation.
(3) (Blank). In reaching a decision, the assigned
independent review organization is not bound by any
decisions or conclusions reached during the health

09700HB0224sam001 - 33 - LRB097 05693 RPM 55431 a
carrier's utilization review process or the health
carrier's internal grievance or appeals process.
(4) Upon receipt of a notice of a decision reversing
the adverse determination or final adverse determination,
the health carrier immediately shall approve the coverage
that was the subject of the adverse determination or final
adverse determination.
(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)
(215 ILCS 180/40)
Sec. 40. Expedited external review.
(a) A covered person or a covered person's authorized
representative may file a request for an expedited external
review with the Director health carrier either orally or in
writing:
(1) immediately after the date of receipt of a notice
prior to a final adverse determination as provided by
subsection (b) of Section 20 of this Act;
(2) immediately after the date of receipt of a notice
upon a final adverse determination as provided by
subsection (c) of Section 20 of this Act; or
(3) if a health carrier fails to provide a decision on
request for an expedited internal appeal within 48 hours as
provided by item (2) of Section 30 of this Act.
(b) Upon receipt of a request for an expedited external
review, the Director shall immediately send a copy of the

09700HB0224sam001 - 34 - LRB097 05693 RPM 55431 a
request to the health carrier. Immediately upon receipt of the
request for an expedited external review as provided under
subsections (b) and (c) of Section 20, the health carrier shall
determine whether the request meets the reviewability
requirements set forth in items (1), (2), and (4) of subsection
(b) of Section 35. In such cases, the following provisions
shall apply:
(1) The health carrier shall immediately notify the
Director, the covered person, and, if applicable, the
covered person's authorized representative of its
eligibility determination.
(2) The notice of initial determination 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 an external
review request is ineligible for review may be appealed to
the Director.
(3) The Director may determine that a request is
eligible for expedited external review notwithstanding a
health carrier's initial determination that the request is
ineligible and require that it be referred for external
review.
(4) In making a determination under item (3) of this
subsection (b), the Director's decision shall be made in
accordance with the terms of the covered person's health
benefit plan, unless such terms are inconsistent with

09700HB0224sam001 - 35 - LRB097 05693 RPM 55431 a
applicable law, and shall be subject to all applicable
provisions of this Act.
(5) The Director may specify the form for the health
carrier's notice of initial determination under this
subsection (b) and any supporting information to be
included in the notice.
(c) Upon receipt of the notice that the request meets the
reviewability requirements, determining that a request meets
the requirements of subsections (b) and (c) of Section 20, the
Director health carrier shall immediately assign an
independent review organization from the list of approved
independent review organizations compiled and maintained by
the Director to conduct the expedited review. In such cases,
the following provisions shall apply:
(1) 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.
(2) The Director shall immediately notify the health
carrier of the name of the assigned independent review
organization. Immediately upon receipt from the Director
of the name of the independent review organization assigned
to conduct the external review assigning an independent
review organization to perform an expedited external

09700HB0224sam001 - 36 - LRB097 05693 RPM 55431 a
review, but in no case more than 24 hours after receiving
such notice assigning the independent review organization,
the health carrier or its designee utilization review
organization shall provide or transmit all necessary
documents and information considered in making the adverse
determination or final adverse determination to the
assigned independent review organization electronically or
by telephone or facsimile or any other available
expeditious method.
(3) If the health carrier or its utilization review
organization fails to provide the documents and
information within the specified timeframe, the assigned
independent review organization may terminate the external
review and make a decision to reverse the adverse
determination or final adverse determination.
(4) 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 (3) of this subsection (c), the
independent review organization shall notify the Director,
the health carrier, the covered person, and, if applicable,
the covered person's authorized representative of its
decision to reverse the adverse determination or final
adverse determination.
(d) In addition to the documents and information provided
by the health carrier or its utilization review organization

09700HB0224sam001 - 37 - LRB097 05693 RPM 55431 a
and any documents and information provided by the covered
person and the covered person's authorized representative, the
independent review organization, to the extent the information
or documents are available and the independent review
organization considers them appropriate, shall consider
information as required by subsection (i) of Section 35 of this
Act in reaching a decision.
(e) As expeditiously as the covered person's medical
condition or circumstances requires, but in no event more than
72 hours after the date of receipt of the request for an
expedited external review 2 business days after the receipt of
all pertinent information, the assigned independent review
organization shall:
(1) make a decision to uphold or reverse the final
adverse determination; and
(2) notify the Director, the health carrier, the
covered person, the covered person's health care provider,
and, if applicable, the covered person's authorized
representative, of the decision.
(f) In reaching a decision, the assigned independent review
organization is not bound by any decisions or conclusions
reached during the health carrier's utilization review process
or the health carrier's internal appeal grievance process as
set forth in the Managed Care Reform and Patient Rights Act.
(g) Upon receipt of notice of a decision reversing the
adverse determination or final adverse determination, the

09700HB0224sam001 - 38 - LRB097 05693 RPM 55431 a
health carrier shall immediately approve the coverage that was
the subject of the adverse determination or final adverse
determination.
(h) If the notice provided pursuant to subsection (e) of
this Section was not in writing, then within Within 48 hours
after the date of providing that the notice required in item
(2) of subsection (e), the assigned independent review
organization shall provide written confirmation of the
decision to the Director, the health carrier, the covered
person, and, if applicable, the covered person's authorized
representative including the information set forth in
subsection (j) of Section 35 of this Act as applicable.
(i) An expedited external review may not be provided for
retrospective adverse or final adverse determinations.
(j) The assignment by the Director of an approved
independent review organization to conduct an external review
in accordance with this Section shall be done on a random basis
among those independent review organizations approved by the
Director pursuant to this Act.
(Source: P.A. 96-857, eff. 7-1-10; revised 9-16-10.)
(215 ILCS 180/42 new)
Sec. 42. External review of experimental or
investigational treatment adverse determinations.
(a) Within 4 months after the date of receipt of a notice
of an adverse determination or final adverse determination that

09700HB0224sam001 - 39 - LRB097 05693 RPM 55431 a
involves a denial of coverage based on a determination that the
health care service or treatment recommended or requested is
experimental or investigational, a covered person or the
covered person's authorized representative may file a request
for an external review with the Director.
(b) The following provisions apply to cases concerning
expedited external reviews:
(1) A covered person or the covered person's authorized
representative may make an oral request for an expedited
external review of the adverse determination or final
adverse determination pursuant to subsection (a) of this
Section if the covered person's treating physician
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.
(2) Upon receipt of a request for an expedited external
review, the Director shall immediately notify the health
carrier.
(3) The following provisions apply concerning notice:
(A) Upon notice of the request for an expedited
external review, the health carrier shall immediately
determine whether the request meets the reviewability
requirements of subsection (d) of this Section. The
health carrier shall immediately notify the Director
and the covered person and, if applicable, the covered

09700HB0224sam001 - 40 - LRB097 05693 RPM 55431 a
person's authorized representative of its eligibility
determination.
(B) The Director may specify the form for the
health carrier's notice of initial determination under
subdivision (A) of this item (3) and any supporting
information to be included in the notice.
(C) The notice of initial determination under
subdivision (A) of this item (3) 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.
(4) The following provisions apply concerning the
Director's determination:
(A) The Director may determine that a request is
eligible for external review under subsection (d) of
this Section notwithstanding a health carrier's
initial determination that the request is ineligible
and require that it be referred for external review.
(B) In making a determination under subdivision
(A) of this item (4), the Director's decision shall be
made in accordance with the terms of the covered
person's health benefit plan, unless such terms are
inconsistent with applicable law, and shall be subject
to all applicable provisions of this Act.

09700HB0224sam001 - 41 - LRB097 05693 RPM 55431 a
(5) Upon receipt of the notice that the expedited
external review request meets the reviewability
requirements of subsection (d) of this Section, the
Director shall immediately assign an independent review
organization to review the expedited request from the list
of approved independent review organizations compiled and
maintained by the Director and notify the health carrier of
the name of the assigned independent review organization.
(6) At the time the health carrier receives the notice
of the assigned independent review organization, the
health carrier or its designee utilization review
organization shall provide or transmit all necessary
documents and information considered in making the adverse
determination or final adverse determination to the
assigned independent review organization electronically or
by telephone or facsimile or any other available
expeditious method.
(c) Except for a request for an expedited external review
made pursuant to subsection (b) of this Section, within one
business day after the date of receipt of a request for
external review, the Director shall send a copy of the request
to the health carrier.
(d) 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

09700HB0224sam001 - 42 - LRB097 05693 RPM 55431 a
health benefit plan at the time the health care service was
recommended or requested or, in the case of a retrospective
review, at the time the health care service was provided;
(2) the recommended or 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;
(3) the covered person's health care provider 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;
or
(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;
(4) the covered person's health care provider:

09700HB0224sam001 - 43 - LRB097 05693 RPM 55431 a
(A) has recommended a health care service or
treatment that the physician certifies, in writing, is
likely to be more beneficial to the covered person, in
the physician's opinion, than any available standard
health care services or treatments; or
(B) who is a licensed, board certified or board
eligible physician qualified to practice in the area of
medicine appropriate to treat the covered person's
condition, has certified in writing that
scientifically valid studies using accepted protocols
demonstrate that the health care service or treatment
requested by the covered person that is the subject of
the adverse determination or final adverse
determination is likely to be more beneficial to the
covered person than any available standard health care
services or treatments;
(5) the covered person has exhausted the health
carrier's internal appeal process, unless the covered
person is not required to exhaust the health carrier's
internal appeal process pursuant to Section 30 of this Act;
and
(6) the covered person has provided all the information
and forms required to process an external review, as
specified in this Act.
(e) The following provisions apply concerning requests:
(1) Within one business day after completion of the

09700HB0224sam001 - 44 - LRB097 05693 RPM 55431 a
preliminary review, the health carrier shall notify the
Director and covered person and, if applicable, the covered
person's authorized representative in writing whether the
request is complete and eligible for external review.
(2) If the request:
(A) is not complete, then the health carrier shall
inform the Director and 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
(B) is not eligible for external review, then the
health carrier shall inform the Director and the
covered person and, if applicable, the covered
person's authorized representative in writing and
include in the notice the reasons for its
ineligibility.
(3) The Department may specify the form for the health
carrier's notice of initial determination under this
subsection (e) and any supporting information to be
included in the notice.
(4) 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

09700HB0224sam001 - 45 - LRB097 05693 RPM 55431 a
ineligible for review may be appealed to the Director by
filing a complaint with the Director.
(5) 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, unless such terms are inconsistent with
applicable law, and shall be subject to all applicable
provisions of this Act.
(f) Whenever a request for external review is determined
eligible for external review, the health carrier shall notify
the Director and the covered person and, if applicable, the
covered person's authorized representative.
(g) Whenever the Director receives notice that a request is
eligible for external review following the preliminary review
conducted pursuant to this Section, within one business day
after the date of receipt of the notice, the Director shall:
(1) assign an independent review organization from the
list of approved independent review organizations compiled
and maintained by the Director pursuant to this Act and
notify the health carrier of the name of the assigned
independent review organization; and
(2) notify in writing the covered person and, if

09700HB0224sam001 - 46 - LRB097 05693 RPM 55431 a
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 Director 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 (g), 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.
(h) The following provisions apply concerning assignments
and clinical reviews:
(1) Within one business day after the receipt of the
notice of assignment to conduct the external review
pursuant to subsection (g) of this Section, the assigned
independent review organization shall select one or more
clinical reviewers, as it determines is appropriate,
pursuant to item (2) of this subsection (h) to conduct the
external review.
(2) The provisions of this item (2) apply concerning
the selection of reviewers:

09700HB0224sam001 - 47 - LRB097 05693 RPM 55431 a
(A) In selecting clinical reviewers pursuant to
item (1) of this subsection (h), the assigned
independent review organization shall select
physicians or other health care professionals who meet
the minimum qualifications described in Section 55 of
this Act and, through clinical experience in the past 3
years, are experts in the treatment of the covered
person's condition and knowledgeable about the
recommended or requested health care service or
treatment.
(B) Neither the covered person, the covered
person's authorized representative, if applicable, nor
the health carrier shall choose or control the choice
of the physicians or other health care professionals to
be selected to conduct the external review.
(3) In accordance with subsection (l) of this Section,
each clinical reviewer shall provide a written opinion to
the assigned independent review organization on whether
the recommended or requested health care service or
treatment should be covered.
(4) In reaching an opinion, clinical reviewers are not
bound by any decisions or conclusions reached during the
health carrier's utilization review process or the health
carrier's internal appeal process.
(i) Within 5 business days after the date of receipt of the
notice provided pursuant to subsection (g) of this Section, the

09700HB0224sam001 - 48 - LRB097 05693 RPM 55431 a
health carrier or its designee utilization review organization
shall 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
(i), 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) Immediately upon 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 (i), the independent review
organization shall notify the Director, the health
carrier, the covered person, and, if applicable, the
covered person's authorized representative of its decision
to reverse the adverse determination.
(j) Upon receipt of the information from the health carrier
or its utilization review organization, each clinical reviewer

09700HB0224sam001 - 49 - LRB097 05693 RPM 55431 a
selected pursuant to subsection (h) of this Section 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.
(k) 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 one
business day. In such cases, the following provisions shall
apply:
(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 be terminated only 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) Immediately upon making its decision to

09700HB0224sam001 - 50 - LRB097 05693 RPM 55431 a
reverse its adverse determination or final adverse
determination, the health carrier shall notify the
Director, 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.
(l) The following provisions apply concerning clinical
review opinions:
(1) Except as provided in item (3) of this subsection
(l), within 20 days after being selected in accordance with
subsection (h) of this Section to conduct the external
review, each clinical reviewer shall provide an opinion to
the assigned independent review organization on whether
the recommended or requested health care service or
treatment should be covered.
(2) Except for an opinion provided pursuant to item (3)
of this subsection (l), each clinical reviewer's opinion
shall be in writing and include the following information:
(A) a description of the covered person's medical
condition;
(B) a description of the indicators relevant to

09700HB0224sam001 - 51 - LRB097 05693 RPM 55431 a
determining whether there is sufficient evidence to
demonstrate that the recommended or requested health
care service or treatment is more likely than not to be
beneficial to the covered person than any available
standard health care services or treatments and the
adverse risks of the recommended or requested health
care service or treatment would not be substantially
increased over those of available standard health care
services or treatments;
(C) a description and analysis of any medical or
scientific evidence considered in reaching the
opinion;
(D) a description and analysis of any
evidence-based standard; and
(E) information on whether the reviewer's
rationale for the opinion is based on clause (A) or (B)
of item (5) of subsection (m) of this Section.
(3) The provisions of this item (3) apply concerning
the timing of opinions:
(A) For an expedited external review, each
clinical reviewer shall provide an opinion orally or in
writing to the assigned independent review
organization as expeditiously as the covered person's
medical condition or circumstances requires, but in no
event more than 5 calendar days after being selected in
accordance with subsection (h) of this Section.

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

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

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opinion of each clinical reviewer, the assigned
independent review organization, in accordance with
item (2) of this subsection (n), shall make a decision
and provide written notice of the decision to the
Director, the health carrier, the covered person, and
the covered person's authorized representative, if
applicable.
(B) For an expedited external review, within 48
hours after the date it receives the opinion of each
clinical reviewer, the assigned independent review
organization, in accordance with item (2) of this
subsection (n), shall make a decision and provide
notice of the decision orally or in writing to the
Director, the health carrier, the covered person, and
the covered person's authorized representative, if
applicable. If such notice is not in writing, within 48
hours after the date of providing that notice, the
assigned independent review organization shall provide
written confirmation of the decision to the Director,
the health carrier, the covered person, and the covered
person's authorized representative, if applicable.
(2) The provisions of this item (2) apply concerning
recommendations:
(A) If a majority of the clinical reviewers
recommend that the recommended or requested health
care service or treatment should be covered, then the

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independent review organization shall make a decision
to reverse the health carrier's adverse determination
or final adverse determination.
(B) If a majority of the clinical reviewers
recommend that the recommended or requested health
care service or treatment should not be covered, the
independent review organization shall make a decision
to uphold the health carrier's adverse determination
or final adverse determination.
(C) The provisions of this subdivision (C) apply to
cases in which the clinical reviewers are evenly split:
(i) If the clinical reviewers are evenly split
as to whether the recommended or requested health
care service or treatment should be covered, then
the independent review organization shall obtain
the opinion of an additional clinical reviewer in
order for the independent review organization to
make a decision based on the opinions of a majority
of the clinical reviewers pursuant to subdivision
(A) or (B) of this item (2).
(ii) The additional clinical reviewer selected
under clause (i) of this subdivision (C) shall use
the same information to reach an opinion as the
clinical reviewers who have already submitted
their opinions.
(iii) The selection of the additional clinical

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

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

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

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

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

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

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

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

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final adverse determination; and
(D) the number of requests for expedited external
review resolved reversing the adverse determination or
final adverse determination;
(5) the average length of time for resolution for an
external review;
(6) the average length of time for resolution for an
expedited external review;
(7) a summary of the types of coverages or cases for
which an external review was sought, as specified below:
(A) denial of care or treatment (dissatisfaction
regarding prospective non-authorization of a request
for care or treatment recommended by a provider
excluding diagnostic procedures and referral requests;
partial approvals and care terminations are also
considered to be denials);
(B) denial of diagnostic procedure
(dissatisfaction regarding prospective
non-authorization of a request for a diagnostic
procedure recommended by a provider; partial approvals
are also considered to be denials);
(C) denial of referral request (dissatisfaction
regarding non-authorization of a request for a
referral to another provider recommended by a PCP);
(D) claims and utilization review (dissatisfaction
regarding the concurrent or retrospective evaluation

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

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