Bill Text: IL HB0711 | 2021-2022 | 102nd General Assembly | Engrossed

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

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Bill Title: Creates the Prior Authorization Reform Act. Provides requirements concerning disclosure and review of prior authorization requirements, denial of claims or coverage by a utilization review organization, and the implementation of prior authorization requirements or restrictions. Provides requirements concerning a utilization review organization's obligations with respect to prior authorizations in nonurgent circumstances, urgent health care services, and emergency health care services. Provides that a utilization review organization shall not require prior authorization under specified circumstances. Provides requirements concerning the length of prior authorizations. Provides that health care services are automatically deemed authorized if a utilization review organization fails to comply with the requirements of the Act. Provides that the Director of Insurance may impose an administrative fine not to exceed $250,000 for violations of the Act. Defines terms. Amends the Illinois Insurance Code to change the definition of "emergency medical condition". Amends the Managed Care Reform and Patient Rights Act to provide that companies that transact accident and health insurance shall comply with specified requirements of the Managed Care Reform and Patient Rights Act. Amends the Illinois Public Aid Code to provide that all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act. Makes other changes. Effective January 1, 2022.

Spectrum: Slight Partisan Bill (Democrat 65-27)

Status: (Passed) 2021-08-19 - Public Act . . . . . . . . . 102-0409 [HB0711 Detail]

Download: Illinois-2021-HB0711-Engrossed.html

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AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. Short title. This Act may be cited as the Prior
Authorization Reform Act.
Section 5. Purpose. The General Assembly hereby finds and
declares that:
(1) the health care professional-patient relationship
is paramount and should not be subject to third-party
intrusion;
(2) prior authorization programs shall be subject to
member coverage agreements and medical policies but shall
not hinder the independent medical judgment of a physician
or health care provider; and
(3) prior authorization programs must be transparent
to ensure a fair and consistent process for health care
providers and patients.
Section 10. Applicability; scope. This Act applies to
health insurance coverage as defined in the Illinois Health
Insurance Portability and Accountability Act, and policies
issued or delivered in this State to the Department of
Healthcare and Family Services and providing coverage to

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persons who are enrolled under Article V of the Illinois
Public Aid Code or under the Children's Health Insurance
Program Act, amended, delivered, issued, or renewed on or
after the effective date of this Act, with the exception of
employee or employer self-insured health benefit plans under
the federal Employee Retirement Income Security Act of 1974,
health care provided pursuant to the Workers' Compensation Act
or the Workers' Occupational Diseases Act, and State employee
health plans. This Act does not diminish a health care plan's
duties and responsibilities under other federal or State law
or rules promulgated thereunder.
Section 15. Definitions. As used in this Act:
"Adverse determination" has the meaning given to that term
in Section 10 of the Health Carrier External Review Act.
"Appeal" means a formal request, either orally or in
writing, to reconsider an adverse determination.
"Approval" means a determination by a utilization review
organization that a health care service has been reviewed and,
based on the information provided, satisfies the utilization
review organization's requirements for medical necessity and
appropriateness.
"Clinical review criteria" has the meaning given to that
term in Section 10 of the Health Carrier External Review Act.
"Department" means the Department of Insurance.
"Emergency medical condition" has the meaning given to

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that term in Section 10 of the Managed Care Reform and Patient
Rights Act.
"Emergency services" has the meaning given to that term in
federal health insurance reform requirements for the group and
individual health insurance markets, 45 CFR 147.138.
"Enrollee" has the meaning given to that term in Section
10 of the Managed Care Reform and Patient Rights Act.
"Health care professional" has the meaning given to that
term in Section 10 of the Managed Care Reform and Patient
Rights Act.
"Health care provider" has the meaning given to that term
in Section 10 of the Managed Care Reform and Patient Rights
Act.
"Health care service" means any services or level of
services included in the furnishing to an individual of
medical care or the hospitalization incident to the furnishing
of such care, as well as the furnishing to any person of any
other services for the purpose of preventing, alleviating,
curing, or healing human illness or injury, including
behavioral health, mental health, home health, and
pharmaceutical services and products.
"Health insurance issuer" has the meaning given to that
term in Section 5 of the Illinois Health Insurance Portability
and Accountability Act.
"Medically necessary" means a health care professional
exercising prudent clinical judgment would provide care to a

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patient for the purpose of preventing, diagnosing, or treating
an illness, injury, disease, or its symptoms and that are: (i)
in accordance with generally accepted standards of medical
practice; (ii) clinically appropriate in terms of type,
frequency, extent, site, and duration and are considered
effective for the patient's illness, injury, or disease; and
(iii) not primarily for the convenience of the patient,
treating physician, other health care professional, caregiver,
family member, or other interested party, but focused on what
is best for the patient's health outcome.
"Physician" means a person licensed under the Medical
Practice Act of 1987 to practice medicine in all its branches.
"Prior authorization" means the process by which
utilization review organizations determine the medical
necessity and medical appropriateness of otherwise covered
health care services before the rendering of such health care
services. "Prior authorization" includes any utilization
review organization's requirement that an enrollee, health
care professional, or health care provider notify the
utilization review organization before, at the time of, or
concurrent to providing a health care service.
"Urgent health care service" means a health care service
with respect to which the application of the time periods for
making a non-expedited prior authorization that in the opinion
of a health care professional with knowledge of the enrollee's
medical condition:

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(1) could seriously jeopardize the life or health of
the enrollee or the ability of the enrollee to regain
maximum function; or
(2) could subject the enrollee to severe pain that
cannot be adequately managed without the care or treatment
that is the subject of the utilization review.
"Urgent health care service" does not include emergency
services.
"Utilization review organization" has the meaning given to
that term in 50 Ill. Adm. Code 4520.30.
Section 20. Disclosure and review of prior authorization
requirements.
(a) A health insurance issuer shall maintain a complete
list of services for which prior authorization is required,
including for all services where prior authorization is
performed by an entity under contract with the health
insurance issuer.
(b) A health insurance issuer shall make any current prior
authorization requirements and restrictions, including the
written clinical review criteria, readily accessible and
conspicuously posted on its website to enrollees, health care
professionals, and health care providers. Content published by
a third party and licensed for use by a health insurance issuer
or its contracted utilization review organization may be made
available through the health insurance issuer's or its

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contracted utilization review organization's secure,
password-protected website so long as the access requirements
of the website do not unreasonably restrict access.
Requirements shall be described in detail, written in easily
understandable language, and readily available to the health
care professional and health care provider at the point of
care. The website shall indicate for each service subject to
prior authorization:
(1) when prior authorization became required for
policies issued or delivered in Illinois, including the
effective date or dates and the termination date or dates,
if applicable, in Illinois;
(2) the date the Illinois-specific requirement was
listed on the health insurance issuer's or its contracted
utilization review organization's website; and
(3) where applicable, the date that prior
authorization was removed for Illinois.
(c) The clinical review criteria must:
(1) be based on nationally recognized, generally
accepted standards except where State law provides its own
standard;
(2) be developed in accordance with the current
standards of a national medical accreditation entity;
(3) ensure quality of care and access to needed health
care services;
(4) be evidence-based;

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(5) be sufficiently flexible to allow deviations from
norms when justified on a case-by-case basis; and
(6) be evaluated and updated, if necessary, at least
annually.
(d) A health insurance issuer shall not deny a claim for
failure to obtain prior authorization if the prior
authorization requirement was not in effect on the date of
service on the claim.
(e) Neither a health insurance issuer nor a contracted
utilization review organization shall deny prior authorization
of a health care service solely based on the grounds that:
(1) no independently developed, evidence-based
standards can be derived from reliable scientific evidence
or documents published by professional societies;
(2) evidence-based standards conflict; or
(3) evidence-based standards from expert consensus
panels do not exist.
(f) A health insurance issuer or its contracted
utilization review organization shall not deem as incidental
or deny supplies or health care services that are routinely
used as part of a health care service when:
(1) an associated health care service has received
prior authorization; or
(2) prior authorization for the health care service is
not required.
(g) If a health insurance issuer intends either to

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implement a new prior authorization requirement or restriction
or amend an existing requirement or restriction, the health
insurance issuer shall provide enrollees, contracted health
care professionals, and contracted health care providers of
enrollees written notice of the new or amended requirement or
amendment no less than 60 days before the requirement or
restriction is implemented. The written notice may be provided
in an electronic format, including email or facsimile, if the
enrollee, health care professional, or health care provider
has agreed in advance to receive notices electronically. The
health insurance issuer shall ensure that the new or amended
requirement is not implemented unless the health insurance
issuer's or its contracted utilization review organization's
website has been updated to reflect the new or amended
requirement or restriction.
(h) Entities utilizing prior authorization shall make
statistics available regarding prior authorization approvals
and denials on their website in a readily accessible format.
The categories must be updated quarterly and include all of
the following information:
(1) a list of all health care services, including
medications, that are subject to prior authorization;
(2) the total number of prior authorization requests
received;
(3) the number of prior authorization requests denied
during the previous plan year by the health insurance

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issuer or its contracted utilization review organization
with respect to each service described in paragraph (1)
and the top 5 reasons for denial;
(4) the number of requests described in paragraph (3)
that were appealed, the number of the appealed requests
that upheld the adverse determination, and the number of
appealed requests that reversed the adverse determination;
(5) the average time between submission and response;
and
(6) any other information as the Director determines
appropriate.
Section 25. Health insurance issuer's and its contracted
utilization review organization's obligations with respect to
prior authorizations in nonurgent circumstances. If a health
insurance issuer requires prior authorization of a health care
service, the health insurance issuer or its contracted
utilization review organization must make an approval or
adverse determination and notify the enrollee, the enrollee's
health care professional, and the enrollee's health care
provider of the approval or adverse determination as required
by applicable law, but no later than 72 hours after obtaining
all necessary information to make the approval or adverse
determination. As used in this Section, "necessary
information" includes the results of any face-to-face clinical
evaluation or second opinion that may be required.

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Section 30. Health insurance issuer's and its contracted
utilization review organization's obligations with respect to
prior authorizations concerning urgent health care services.
(a) A health insurance issuer or its contracted
utilization review organization must render an approval or
adverse determination concerning urgent care services and any
services for any current or prospective resident of a skilled
nursing facility and notify the enrollee, the enrollee's
health care professional, and the enrollee's health care
provider of that approval or adverse determination not later
than 24 hours after receiving all information needed to
complete the review of the requested health care services.
(b) To facilitate the rendering of a prior authorization
determination in conformance with this Section, a health
insurance issuer or its contracted utilization review
organization must establish and provide access to a hotline
that is staffed 24 hours per day, 7 days per week by
appropriately trained and licensed clinical personnel who have
access to physicians for consultation, designated by the plan
to make such determinations for prior authorization concerning
urgent care services.
Section 35. Health insurance issuer's and its contracted
utilization review organization's obligations with respect to
prior authorization concerning emergency health care services.

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(a) A health insurance issuer shall cover emergency health
care services necessary to screen and stabilize an enrollee.
If a health care professional or health care provider
certifies in writing to a health insurance issuer within 72
hours after an enrollee's admission that the enrollee's
condition required emergency health care services, that
certification shall create a presumption that the emergency
health care services were medically necessary and such
presumption may be rebutted only if the health insurance
issuer or its contracted utilization review organization can
establish, with clear and convincing evidence, that the
emergency health care services were not medically necessary.
(b) If an enrollee receives an emergency health care
service that requires immediate post-evaluation or
post-stabilization services, a health insurance issuer or its
contracted utilization review organization shall make a prior
authorization determination within 60 minutes after receiving
a request; if the prior authorization determination is not
made within 60 minutes, the services shall be deemed approved.
Section 40. Personnel qualified to make adverse
determinations of a prior authorization request. A health
insurance issuer or its contracted utilization review
organization must ensure that all adverse determinations are
made by a physician when the request is by a physician or a
representative of a physician. The physician must:

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(1) possess a current and valid nonrestricted license
to practice medicine in all its branches in any United
States jurisdiction;
(2) practice in the same or similar specialty as the
physician who typically manages the medical condition or
disease or provides the health care service involved in
the request; and
(3) have experience treating patients with the medical
condition or disease for which the health care service is
being requested.
Notwithstanding the foregoing, a licensed health care
professional who satisfies the requirements of this Section
may make an adverse determination of a prior authorization
request submitted by a health care professional licensed in
the same profession.
Section 45. Consultation before issuing an adverse
determination of a prior authorization. If a health insurance
issuer or its contracted utilization review organization is
questioning the medical necessity of a health care service,
the health insurance issuer or its contracted utilization
review organization must notify the enrollee's health care
professional and health care provider that medical necessity
is being questioned. Before issuing an adverse determination,
the enrollee's health care professional and health care
provider must have the opportunity to discuss the medical

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necessity of the health care service on the telephone or by
other agreeable method with the health care professional who
will be responsible for issuing the prior authorization
determination of the health care service under review.
Section 50. Requirements applicable to the physician who
can review consultations and appeals. A health insurance
issuer or its contracted utilization review organization must
ensure that all appeals are reviewed by a physician. The
physician must:
(1) possess a current and valid nonrestricted license
to practice medicine in any United States jurisdiction;
(2) be currently in active practice in the same or
similar specialty as a physician who typically manages the
medical condition or disease;
(3) be knowledgeable of, and have experience
providing, the health care services under appeal;
(4) not have been directly involved in making the
adverse determination; and
(5) consider all known clinical aspects of the health
care service under review, including, but not limited to,
a review of all pertinent medical records provided to the
health insurance issuer or its contracted utilization
review organization by the enrollee's health care
professional or health care provider and any medical
literature provided to the health insurance issuer or its

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contracted utilization review organization by the health
care professional or health care provider.
Section 55. Review of prior authorization requirements. A
health insurance issuer shall periodically review its prior
authorization requirements and consider removal of prior
authorization requirements:
(1) where a medication or procedure prescribed is
customary and properly indicated or is a treatment for the
clinical indication as supported by peer-reviewed medical
publications; or
(2) for patients currently managed with an established
treatment regimen.
Section 60. Denial.
(a) The health insurance issuer or its contracted
utilization review organization may not revoke, limit,
condition, or restrict a previously issued prior authorization
approval.
(b) Notwithstanding any other provision of law, if a claim
is properly coded and submitted timely to a health insurance
issuer, the health insurance issuer shall make payment on
claims for health care services for which prior authorization
was required and approval received before the rendering of
health care services, unless one of the following occurs:
(1) it is timely determined that the enrollee's health

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care professional or health care provider knowingly
provided health care services that required prior
authorization from the health insurance issuer or its
contracted utilization review organization without first
obtaining prior authorization for those health care
services;
(2) it is timely determined that the health care
services claimed were not performed;
(3) it is timely determined that the health care
services rendered were contrary to the instructions of the
health insurance issuer or its contracted utilization
review organization or delegated physician reviewer if
contact was made between those parties before the service
being rendered;
(4) it is timely determined that the enrollee
receiving such health care services was not an enrollee of
the health care plan; or
(5) the approval was based upon a material
misrepresentation by the enrollee or health care provider;
as used in this paragraph (5), "material" means a fact or
situation that is not merely technical in nature and
results or could result in a substantial change in the
situation.
Section 65. Length of prior authorization approval. A
prior authorization approval shall be valid for the lesser of

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12 months after the date the health care professional or
health care provider receives the prior authorization approval
or the length of treatment as determined by the patient's
health care professional, and the approval period shall be
effective regardless of any changes, including any changes in
dosage for a prescription drug prescribed by the health care
professional. This Section shall not apply to the prescription
of benzodiazepines or Schedule II narcotic drugs, such as
opioids. Except to the extent required by medical exceptions
processes for prescription drugs, nothing in this Section
shall require a policy to cover any care, treatment, or
services for any health condition that the terms of coverage
otherwise completely exclude from the policy's covered
benefits without regard for whether the care, treatment, or
services are medically necessary.
Section 70. Length of prior authorization approval for
treatment for chronic or long-term conditions. If a health
insurance issuer requires a prior authorization for a
recurring health care service or maintenance medication for
the treatment of a chronic or long-term condition, the
approval shall remain valid for the lesser of 12 months from
the date the health care professional or health care provider
receives the prior authorization approval or the length of the
treatment as determined by the patient's health care
professional. Except to the extent required by medical

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exceptions processes for prescription drugs, nothing in this
Section shall require a policy to cover any care, treatment,
or services for any health condition that the terms of
coverage otherwise completely exclude from the policy's
covered benefits without regard for whether the care,
treatment, or services are medically necessary.
Section 75. Continuity of care for enrollees.
(a) On receipt of information documenting a prior
authorization approval from the enrollee or from the
enrollee's health care professional or health care provider, a
health insurance issuer shall honor a prior authorization
granted to an enrollee from a previous health insurance issuer
or its contracted utilization review organization for at least
the initial 90 days of an enrollee's coverage under a new
health plan.
(b) During the time period described in subsection (a), a
health insurance issuer or its contracted utilization review
organization may perform its own review to grant a prior
authorization approval subject to the terms of the member's
coverage agreement.
(c) If there is a change in coverage of or approval
criteria for a previously authorized health care service, the
change in coverage or approval criteria does not affect an
enrollee who received prior authorization approval before the
effective date of the change for the remainder of the

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enrollee's plan year.
(d) Except to the extent required by medical exceptions
processes for prescription drugs, nothing in this Section
shall require a policy to cover any care, treatment, or
services for any health condition that the terms of coverage
otherwise completely exclude from the policy's covered
benefits without regard for whether the care, treatment, or
services are medically necessary.
Section 80. Health care services deemed authorized if a
health insurance issuer or its contracted utilization review
organization fails to comply with the requirements of this
Act. A failure by a health insurance issuer or its contracted
utilization review organization to comply with the deadlines
and other requirements specified in this Act shall result in
any health care services subject to review to be automatically
deemed authorized by the health insurance issuer or its
contracted utilization review organization.
Section 85. Severability. If any provision of this Act or
its application to any person or circumstance is held invalid,
the invalidity does not affect other provisions or
applications of this Act that can be given effect without the
invalid provision or application, and to this end the
provisions of this Act are declared to be severable.

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Section 90. Administration and enforcement.
(a) The Department shall enforce the provisions of this
Act pursuant to the enforcement powers granted to it by law. To
enforce the provisions of this Act, the Director is hereby
granted specific authority to issue a cease and desist order
or require a utilization review organization or health
insurance issuer to submit a plan of correction for violations
of this Act, or both, in accordance with the requirements and
authority set forth in Section 85 of the Managed Care Reform
and Patient Rights Act. Subject to the provisions of the
Illinois Administrative Procedure Act, the Director may,
pursuant to Section 403A of the Illinois Insurance Code,
impose upon a utilization review organization or health
insurance issuer an administrative fine not to exceed $250,000
for failure to submit a requested plan of correction, failure
to comply with its plan of correction, or repeated violations
of this Act.
(b) Any person who believes that his or her utilization
review organization or health insurance issuer is in violation
of the provisions of this Act may file a complaint with the
Department. The Department shall review all complaints
received and investigate all complaints that it deems to state
a potential violation. The Department shall fairly,
efficiently, and timely review and investigate complaints.
Utilization review organizations found to be in violation of
this Act shall be penalized in accordance with this Section.

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(c) The Department of Healthcare and Family Services shall
enforce the provisions of this Act as it applies to persons
enrolled under Article V of the Illinois Public Aid Code or
under the Children's Health Insurance Program Act.
Section 900. The Illinois Insurance Code is amended by
changing Section 370g as follows:
(215 ILCS 5/370g) (from Ch. 73, par. 982g)
Sec. 370g. Definitions. As used in this Article, the
following definitions apply:
(a) "Health care services" means health care services or
products rendered or sold by a provider within the scope of the
provider's license or legal authorization. The term includes,
but is not limited to, hospital, medical, surgical, dental,
vision and pharmaceutical services or products.
(b) "Insurer" means an insurance company or a health
service corporation authorized in this State to issue policies
or subscriber contracts which reimburse for expenses of health
care services.
(c) "Insured" means an individual entitled to
reimbursement for expenses of health care services under a
policy or subscriber contract issued or administered by an
insurer.
(d) "Provider" means an individual or entity duly licensed
or legally authorized to provide health care services.

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(e) "Noninstitutional provider" means any person licensed
under the Medical Practice Act of 1987, as now or hereafter
amended.
(f) "Beneficiary" means an individual entitled to
reimbursement for expenses of or the discount of provider fees
for health care services under a program where the beneficiary
has an incentive to utilize the services of a provider which
has entered into an agreement or arrangement with an
administrator.
(g) "Administrator" means any person, partnership or
corporation, other than an insurer or health maintenance
organization holding a certificate of authority under the
"Health Maintenance Organization Act", as now or hereafter
amended, that arranges, contracts with, or administers
contracts with a provider whereby beneficiaries are provided
an incentive to use the services of such provider.
(h) "Emergency medical condition" has the meaning given to
that term in Section 10 of the Managed Care Reform and Patient
Rights Act. means a medical condition manifesting itself by
acute symptoms of sufficient severity (including 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;

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(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
(Source: P.A. 91-617, eff. 1-1-00.)
Section 905. The Managed Care Reform and Patient Rights
Act is amended by changing Sections 10 and 65 as follows:
(215 ILCS 134/10)
Sec. 10. Definitions.
"Adverse determination" means a determination by a health
care plan under Section 45 or by a utilization review program
under Section 85 that a health care service is not medically
necessary.
"Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
"Department" means the Department of Insurance.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
regardless of the final diagnosis given, 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

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unborn child) in serious jeopardy;
(2) serious impairment to bodily functions;
(3) serious dysfunction of any bodily organ or part;
(4) inadequately controlled pain; or
(5) with respect to a pregnant woman who is having
contractions:
(A) inadequate time to complete a safe transfer to
another hospital before delivery; or
(B) a transfer to another hospital may pose a
threat to the health or safety of the woman or unborn
child.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
"Enrollee" means any person and his or her dependents

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enrolled in or covered by a health care plan.
"Health care plan" means a plan, including, but not
limited to, a health maintenance organization, a managed care
community network as defined in the Illinois Public Aid Code,
or an accountable care entity as defined in the Illinois
Public Aid Code that receives capitated payments to cover
medical services from the Department of Healthcare and Family
Services, that establishes, operates, or maintains a network
of health care providers that has entered into an agreement
with the plan to provide health care services to enrollees to
whom the plan has the ultimate obligation to arrange for the
provision of or payment for services through organizational
arrangements for ongoing quality assurance, utilization review
programs, or dispute resolution. Nothing in this definition
shall be construed to mean that an independent practice
association or a physician hospital organization that
subcontracts with a health care plan is, for purposes of that
subcontract, a health care plan.
For purposes of this definition, "health care plan" shall
not include the following:
(1) indemnity health insurance policies including
those using a contracted provider network;
(2) health care plans that offer only dental or only
vision coverage;
(3) preferred provider administrators, as defined in
Section 370g(g) of the Illinois Insurance Code;

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(4) employee or employer self-insured health benefit
plans under the federal Employee Retirement Income
Security Act of 1974;
(5) health care provided pursuant to the Workers'
Compensation Act or the Workers' Occupational Diseases
Act; and
(6) not-for-profit voluntary health services plans
with health maintenance organization authority in
existence as of January 1, 1999 that are affiliated with a
union and that only extend coverage to union members and
their dependents.
"Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.
"Health care provider" means any physician, hospital
facility, facility licensed under the Nursing Home Care Act,
long-term care facility as defined in Section 1-113 of the
Nursing Home Care Act, or other person that is licensed or
otherwise authorized to deliver health care services. Nothing
in this Act shall be construed to define Independent Practice
Associations or Physician-Hospital Organizations as health
care providers.
"Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all other

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services for the purpose of preventing, alleviating, curing,
or healing human illness or injury including behavioral
health, mental health, home health, and pharmaceutical
services and products.
"Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health
care plan.
"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
"Physician" means a person licensed under the Medical
Practice Act of 1987.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
"Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
"Utilization review" means the evaluation of the medical
necessity, appropriateness, and efficiency of the use of
health care services, procedures, and facilities.

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"Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 101-452, eff. 1-1-20.)
(215 ILCS 134/65)
Sec. 65. Emergency services prior to stabilization.
(a) A health care plan that provides or that is required by
law to provide coverage for emergency services shall provide
coverage such that payment under this coverage is not
dependent upon whether the services are performed by a plan or
non-plan health care provider and without regard to prior
authorization. This coverage shall be at the same benefit
level as if the services or treatment had been rendered by the
health care plan physician licensed to practice medicine in
all its branches or health care provider.
(b) Prior authorization or approval by the plan shall not
be required for emergency services.
(c) Coverage and payment shall only be retrospectively
denied under the following circumstances:
(1) upon reasonable determination that the emergency
services claimed were never performed;
(2) upon timely determination that the emergency
evaluation and treatment were rendered to an enrollee who
sought emergency services and whose circumstance did not
meet the definition of emergency medical condition;
(3) upon determination that the patient receiving such

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services was not an enrollee of the health care plan; or
(4) upon material misrepresentation by the enrollee or
health care provider; "material" means a fact or situation
that is not merely technical in nature and results or
could result in a substantial change in the situation.
(d) When an enrollee presents to a hospital seeking
emergency services, the determination as to whether the need
for those services exists shall be made for purposes of
treatment by a physician licensed to practice medicine in all
its branches or, to the extent permitted by applicable law, by
other appropriately licensed personnel under the supervision
of or in collaboration with a physician licensed to practice
medicine in all its branches. The physician or other
appropriate personnel shall indicate in the patient's chart
the results of the emergency medical screening examination.
(e) The appropriate use of the 911 emergency telephone
system or its local equivalent shall not be discouraged or
penalized by the health care plan when an emergency medical
condition exists. This provision shall not imply that the use
of 911 or its local equivalent is a factor in determining the
existence of an emergency medical condition.
(f) The medical director's or his or her designee's
determination of whether the enrollee meets the standard of an
emergency medical condition shall be based solely upon the
presenting symptoms documented in the medical record at the
time care was sought. Only a clinical peer may make an adverse

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determination.
(g) Nothing in this Section shall prohibit the imposition
of deductibles, copayments, and co-insurance. Nothing in this
Section alters the prohibition on billing enrollees contained
in the Health Maintenance Organization Act.
(h) This Section shall apply to the types of companies
subject to Section 155.36 of the Illinois Insurance Code.
(Source: P.A. 91-617, eff. 1-1-00.)
Section 910. The Illinois Public Aid Code is amended by
adding Section 5-5.12d as follows:
(305 ILCS 5/5-5.12d new)
Sec. 5-5.12d. Managed care organization prior
authorization of health care services.
(a) As used in this Section, "health care service" has the
meaning given to that term in the Prior Authorization Reform
Act.
(b) Notwithstanding any other provision of law to the
contrary, all managed care organizations shall comply with the
requirements of the Prior Authorization Reform Act.
Section 999. Effective date. This Act takes effect January
1, 2022.