Bill Text: IL HB3923 | 2009-2010 | 96th General Assembly | Enrolled

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Bill Title: Creates the Individual Market Fairness Reform Law. Provides that a managed care entity shall (1) fairly and affirmatively offer all of its managed care plans that are sold to all individuals in each service area in which the managed care entity provides or arranges for the provision of health care services and (2) may not reject an application for an individual managed care plan if certain requirements are met. Provides that the Division of Insurance of the Department of Financial and Professional Regulation shall develop a system to categorize all managed care plans offered and sold to individuals pursuant to this Law into 5 coverage choice categories. Creates the Minimum Medical Loss Ratio Law. Provides that any company selling a health benefit plan in the individual or small group market shall expend in the form of health care benefits no less than 85 percent of the aggregate dues, fees, and premiums received by the company. Creates the Health Sure Illinois Law to establish a program for the purpose of making managed care plans affordable and accessible to small employers and individuals. Provides that the program is limited to active managed care entities. Amends the Illinois Insurance Code. Creates new Articles in the Code establishing the Office of Patient Protection and the Illinois Health Carrier External Review Law. Amends the Small Employer Health Insurance Rating Act, Illinois Health Insurance Portability and Accountability Act, and Managed Care Reform and Patient Rights Act in provisions concerning small employers, individuals, review, and rates. Repeals a provision of the Small Employer Health Insurance Rating Act concerning establishment of a class of business. Makes other changes.

Spectrum: Partisan Bill (Democrat 34-0)

Status: (Passed) 2010-01-05 - Public Act . . . . . . . . . 96-0857 [HB3923 Detail]

Download: Illinois-2009-HB3923-Enrolled.html

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AN ACT concerning insurance.
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 Health
Carrier External Review Act.
Section 5. Purpose and intent. The purpose of this Act is
to provide uniform standards for the establishment and
maintenance of external review procedures to assure that
covered persons have the opportunity for an independent review
of an adverse determination or final adverse determination, as
defined in this Act.
Section 10. Definitions. For the purposes of this Act:
"Adverse determination" means a determination by a health
carrier or its designee utilization review organization that an
admission, availability of care, continued stay, or other
health care service that is a covered benefit has been reviewed
and, based upon the information provided, does not meet the
health carrier's requirements for medical necessity,
appropriateness, health care setting, level of care, or
effectiveness, and the requested service or payment for the
service is therefore denied, reduced, or terminated.
"Authorized representative" means:

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(1) a person to whom a covered person has given express
written consent to represent the covered person in an
external review, including the covered person's health
care provider;
(2) a person authorized by law to provide substituted
consent for a covered person; or
(3) the covered person's health care provider when the
covered person is unable to provide consent.
"Best evidence" means evidence based on:
(1) randomized clinical trials;
(2) if randomized clinical trials are not available,
then cohort studies or case-control studies;
(3) if items (1) and (2) are not available, then
case-series; or
(4) if items (1), (2), and (3) are not available, then
expert opinion.
"Case-series" means an evaluation of a series of patients
with a particular outcome, without the use of a control group.
"Clinical review criteria" means the written screening
procedures, decision abstracts, clinical protocols, and
practice guidelines used by a health carrier to determine the
necessity and appropriateness of health care services.
"Cohort study" means a prospective evaluation of 2 groups
of patients with only one group of patients receiving specific
intervention.
"Covered benefits" or "benefits" means those health care

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services to which a covered person is entitled under the terms
of a health benefit plan.
"Covered person" means a policyholder, subscriber,
enrollee, or other individual participating in a health benefit
plan.
"Director" means the Director of the Department of
Insurance.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including, but not limited to, severe pain, such that a prudent
layperson who possesses an average knowledge of health and
medicine could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual or, with
respect to a pregnant woman, the health of the woman or her
unborn child, in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
"Emergency services" means health care items and services
furnished or required to evaluate and treat an emergency
medical condition.
"Evidence-based standard" means the conscientious,
explicit, and judicious use of the current best evidence based
on an overall systematic review of the research in making
decisions about the care of individual patients.
"Expert opinion" means a belief or an interpretation by

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specialists with experience in a specific area about the
scientific evidence pertaining to a particular service,
intervention, or therapy.
"Facility" means an institution providing health care
services or a health care setting.
"Final adverse determination" means an adverse
determination involving a covered benefit that has been upheld
by a health carrier, or its designee utilization review
organization, at the completion of the health carrier's
internal grievance process procedures as set forth by the
Managed Care Reform and Patient Rights Act.
"Health benefit plan" means a policy, contract,
certificate, plan, or agreement offered or issued by a health
carrier to provide, deliver, arrange for, pay for, or reimburse
any of the costs of health care services.
"Health care provider" or "provider" means a physician,
hospital facility, or other health care practitioner licensed,
accredited, or certified to perform specified health care
services consistent with State law, responsible for
recommending health care services on behalf of a covered
person.
"Health care services" means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
"Health carrier" means an entity subject to the insurance
laws and regulations of this State, or subject to the

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jurisdiction of the Director, that contracts or offers to
contract to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services, including a
sickness and accident insurance company, a health maintenance
organization, or any other entity providing a plan of health
insurance, health benefits, or health care services. "Health
carrier" also means Limited Health Service Organizations
(LHSO) and Voluntary Health Service Plans.
"Health information" means information or data, whether
oral or recorded in any form or medium, and personal facts or
information about events or relationships that relate to:
(1) the past, present, or future physical, mental, or
behavioral health or condition of an individual or a member
of the individual's family;
(2) the provision of health care services to an
individual; or
(3) payment for the provision of health care services
to an individual.
"Independent review organization" means an entity that
conducts independent external reviews of adverse
determinations and final adverse determinations.
"Medical or scientific evidence" means evidence found in
the following sources:
(1) peer-reviewed scientific studies published in or
accepted for publication by medical journals that meet
nationally recognized requirements for scientific

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manuscripts and that submit most of their published
articles for review by experts who are not part of the
editorial staff;
(2) peer-reviewed medical literature, including
literature relating to therapies reviewed and approved by a
qualified institutional review board, biomedical
compendia, and other medical literature that meet the
criteria of the National Institutes of Health's Library of
Medicine for indexing in Index Medicus (Medline) and
Elsevier Science Ltd. for indexing in Excerpta Medicus
(EMBASE);
(3) medical journals recognized by the Secretary of
Health and Human Services under Section 1861(t)(2) of the
federal Social Security Act;
(4) the following standard reference compendia:
(a) The American Hospital Formulary Service-Drug
Information;
(b) Drug Facts and Comparisons;
(c) The American Dental Association Accepted
Dental Therapeutics; and
(d) The United States Pharmacopoeia-Drug
Information;
(5) findings, studies, or research conducted by or
under the auspices of federal government agencies and
nationally recognized federal research institutes,
including:

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(a) the federal Agency for Healthcare Research and
Quality;
(b) the National Institutes of Health;
(c) the National Cancer Institute;
(d) the National Academy of Sciences;
(e) the Centers for Medicare & Medicaid Services;
(f) the federal Food and Drug Administration; and
(g) any national board recognized by the National
Institutes of Health for the purpose of evaluating the
medical value of health care services; or
(6) any other medical or scientific evidence that is
comparable to the sources listed in items (1) through (5).
"Protected health information" means health information
(i) that identifies an individual who is the subject of the
information; or (ii) with respect to which there is a
reasonable basis to believe that the information could be used
to identify an individual.
"Retrospective review" means a review of medical necessity
conducted after services have been provided to a patient, but
does not include the review of a claim that is limited to an
evaluation of reimbursement levels, veracity of documentation,
accuracy of coding, or adjudication for payment.
"Utilization review" has the meaning provided by the
Managed Care Reform and Patient Rights Act.
"Utilization review organization" means a utilization
review program as defined in the Managed Care Reform and

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Patient Rights Act.
Section 15. Applicability and scope.
(a) Except as provided in subsection (b) of this Section,
this Act shall apply to all health carriers.
(b) The provisions of this Act shall not apply to a policy
or certificate that provides coverage only for a specified
disease, specified accident or accident-only coverage, credit,
dental, disability income, hospital indemnity, long-term care
insurance as defined by Article XIXA of the Illinois Insurance
Code, vision care, or any other limited supplemental benefit; a
Medicare supplement policy of insurance as defined by the
Director by regulation; coverage under a plan through Medicare,
Medicaid, or the federal employees health benefits program; any
coverage issued under Chapter 55 of Title 10, U.S. Code and any
coverage issued as supplement to that coverage; any coverage
issued as supplemental to liability insurance, workers'
compensation, or similar insurance; automobile medical-payment
insurance or any insurance under which benefits are payable
with or without regard to fault, whether written on a group
blanket or individual basis.
Section 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

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determination as provided by the Managed Care Reform and
Patient Rights Act, a health carrier shall notify a covered
person and a covered person's health care provider in writing
of the covered person's right to request an external review as
provided by this Act. The written notice required shall include
the following, or substantially equivalent, language: "We have
denied your request for the provision of or payment for a
health care service or course of treatment. You have the right
to have our decision reviewed by an independent review
organization not associated with us if our decision involved
making a judgment as to the medical necessity, appropriateness,
health care setting, level of care, or effectiveness of the
health care service or treatment you requested by submitting a
written request for an external review to us. Upon receipt of
your request an independent review organization registered
with the Department of Insurance will be assigned to review our
decision.
(b) This subsection (b) shall apply to an expedited review
prior to a final adverse determination. In addition to the
notice required in subsection (a), the health carrier shall
include a notice related to an adverse determination, a
statement informing the covered person all of the following:
(1) If the covered person has a medical condition where
the timeframe for completion of (A) an expedited internal
review of a grievance involving an adverse determination,
(B) a final adverse determination as set forth in the

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Managed Care Reform and Patient Rights Act, or (C) a
standard external review as established in this Act, would
seriously jeopardize the life or health of the covered
person or would jeopardize the covered person's ability to
regain maximum function, then the covered person or the
covered person's authorized representative may file a
request for an expedited external review.
(2) The covered person or the covered person's
authorized representative may file a request for an
expedited external review at the same time the covered
person or the covered person's authorized representative
files a request for an expedited internal appeal involving
an adverse determination as set forth in the Managed Care
Reform and Patient Rights Act if the adverse determination
involves a denial of coverage based on a determination that
the recommended or requested health care service or
treatment is experimental or investigational and the
covered person's health care provider certifies in writing
that the recommended or requested health care service or
treatment that is the subject of the adverse determination
would be significantly less effective if not promptly
initiated. The independent review organization assigned to
conduct the expedited external review will determine
whether the covered person shall be required to complete
the expedited review of the grievance prior to conducting
the expedited external review.

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(3) If an adverse determination concerns a denial of
coverage based on a determination that the recommended or
requested health care service or treatment is experimental
or investigational and the covered person's health care
provider certifies in writing that the recommended or
requested health care service or treatment that is the
subject of the request would be significantly less
effective if not promptly initiated, then the covered
person or the covered person's authorized representative
may request an expedited external review.
(c) This subsection (c) shall apply to an expedited review
upon final adverse determination. In addition to the notice
required in subsection (a), the health carrier shall include a
notice related to a final adverse determination, a statement
informing the covered person all of the following:
(1) if the covered person has a medical condition where
the timeframe for completion of a standard external review
would seriously jeopardize the life or health of the
covered person or would jeopardize the covered person's
ability to regain maximum function, then the covered person
or the covered person's authorized representative may file
a request for an expedited external review; or
(2) if a final adverse determination concerns an
admission, availability of care, continued stay, or health
care service for which the covered person received
emergency services, but has not been discharged from a

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facility, then the covered person, or the covered person's
authorized representative, may request an expedited
external review; or
(3) if a final adverse determination concerns a denial
of coverage based on a determination that the recommended
or requested health care service or treatment is
experimental or investigational, and the covered person's
health care provider certifies in writing that the
recommended or requested health care service or treatment
that is the subject of the request would be significantly
less effective if not promptly initiated, then the covered
person or the covered person's authorized representative
may request an expedited external review.
(d) In addition to the information to be provided pursuant
to subsections (a), (b), and (c) of this Section, the health
carrier shall include a copy of the description of both the
required standard and expedited external review procedures.
The description shall highlight the external review procedures
that give the covered person or the covered person's authorized
representative the opportunity to submit additional
information, including any forms used to process an external
review.
Section 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

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an adverse determination or final adverse determination.
Requests under this Section shall be made directly to the
health carrier that made the adverse or final adverse
determination. All requests for external review shall be in
writing except for requests for expedited external reviews
which may me made orally. Health carriers must provide covered
persons with forms to request external reviews.
Section 30. Exhaustion of internal grievance process.
Except as provided in subsection (b) of Section 20, a
request for an external review shall not be made until the
covered person has exhausted the health carrier's internal
grievance process as set forth in the Managed Care Reform and
Patient Rights Act. A covered person shall also be considered
to have exhausted the health carrier's internal grievance
process for purposes of this Section if:
(1) the covered person or the covered person's
authorized representative filed a request for an internal
review of an adverse determination pursuant to the Managed
Care Reform and Patient Rights Act and has not received a
written decision on the request from the health carrier
within 15 days after receipt of the required information
but not more than 30 days after the request was filed by
the covered person or the covered person's authorized
representative, except to the extent the covered person or
the covered person's authorized representative requested

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or agreed to a delay; however, a covered person or the
covered person's authorized representative may not make a
request for an external review of an adverse determination
involving a retrospective review determination until the
covered person has exhausted the health carrier's internal
grievance process;
(2) the covered person or the covered person's
authorized representative filed a request for an expedited
internal review of an adverse determination pursuant to the
Managed Care Reform and Patient Rights Act and has not
received a decision on request from the health carrier
within 48 hours, except to the extent the covered person or
the covered person's authorized representative requested
or agreed to a delay; or
(3) the health carrier agrees to waive the exhaustion
requirement.
Section 35. Standard external review.
(a) Within 4 months after the date of receipt of a notice
of an adverse determination or final adverse determination, a
covered person or the covered person's authorized
representative may file a request for an external review with
the health carrier.
(b) Within 5 business days following the date of receipt of
the external review request, the health carrier shall complete
a preliminary review of the request to determine whether:

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(1) the individual is or was a covered person in the
health benefit plan at the time the health care service was
requested or at the time the health care service was
provided;
(2) the health care service that is the subject of the
adverse determination or the final adverse determination
is a covered service under the covered person's health
benefit plan, but the health carrier has determined that
the health care service is not covered because it does not
meet the health carrier's requirements for medical
necessity, appropriateness, health care setting, level of
care, or effectiveness;
(3) the covered person has exhausted the health
carrier's internal grievance process as set forth in this
Act;
(4) for appeals relating to a determination based on
treatment being experimental or investigational, the
requested health care service or treatment that is the
subject of the adverse determination or final adverse
determination is a covered benefit under the covered
person's health benefit plan except for the health
carrier's determination that the service or treatment is
experimental or investigational for a particular medical
condition and is not explicitly listed as an excluded
benefit under the covered person's health benefit plan with
the health carrier and that the covered person's health

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care provider, who is a physician licensed to practice
medicine in all its branches, has certified that one of the
following situations is applicable:
(A) standard health care services or treatments
have not been effective in improving the condition of
the covered person;
(B) standard health care services or treatments
are not medically appropriate for the covered person;
(C) there is no available standard health care
service or treatment covered by the health carrier that
is more beneficial than the recommended or requested
health care service or treatment;
(D) the health care service or treatment is likely
to be more beneficial to the covered person, in the
health care provider's opinion, than any available
standard health care services or treatments; or
(E) that scientifically valid studies using
accepted protocols demonstrate that the health care
service or treatment requested is likely to be more
beneficial to the covered person than any available
standard health care services or treatments; and
(5) the covered person has provided all the information
and forms required to process an external review, as
specified in this Act.
(c) Within one business day after completion of the
preliminary review, the health carrier shall notify the covered

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person and, if applicable, the covered person's authorized
representative in writing whether the request is complete and
eligible for external review. If the request:
(1) is not complete, the health carrier shall inform
the covered person and, if applicable, the covered person's
authorized representative in writing and include in the
notice what information or materials are required by this
Act to make the request complete; or
(2) is not eligible for external review, the health
carrier shall inform the covered person and, if applicable,
the covered person's authorized representative in writing
and include in the notice the reasons for its
ineligibility.
The notice of initial determination of ineligibility shall
include a statement informing the covered person and, if
applicable, the covered person's authorized representative
that a health carrier's initial determination that the external
review request is ineligible for review may be appealed to the
Director by filing a complaint with the Director.
Notwithstanding a health carrier's initial determination
that the request is ineligible for external review, the
Director may determine that a request is eligible for external
review and require that it be referred for external review. In
making such determination, the Director's decision shall be in
accordance with the terms of the covered person's health
benefit plan and shall be subject to all applicable provisions

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of this Act.
(d) Whenever a request is eligible for external review the
health carrier shall, within 5 business days:
(1) assign an independent review organization from the
list of approved independent review organizations compiled
and maintained by the Director; and
(2) notify in writing the covered person and, if
applicable, the covered person's authorized representative
of the request's eligibility and acceptance for external
review and the name of the independent review organization.
The health carrier shall include in the notice provided to
the covered person and, if applicable, the covered person's
authorized representative a statement that the covered person
or the covered person's authorized representative may, within 5
business days following the date of receipt of the notice
provided pursuant to item (2) of this subsection (d), submit in
writing to the assigned independent review organization
additional information that the independent review
organization shall consider when conducting the external
review. The independent review organization is not required to,
but may, accept and consider additional information submitted
after 5 business days.
(e) The assignment of an approved independent review
organization to conduct an external review in accordance with
this Section shall be made from those approved independent
review organizations qualified to conduct external review as

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required by Sections 50 and 55 of this Act.
(f) Upon assignment of an independent review organization,
the health carrier or its designee utilization review
organization shall, within 5 business days, provide to the
assigned independent review organization the documents and any
information considered in making the adverse determination or
final adverse determination; in such cases, the following
provisions shall apply:
(1) Except as provided in item (2) of this subsection
(f), failure by the health carrier or its utilization
review organization to provide the documents and
information within the specified time frame shall not delay
the conduct of the external review.
(2) If the health carrier or its utilization review
organization fails to provide the documents and
information within the specified time frame, the assigned
independent review organization may terminate the external
review and make a decision to reverse the adverse
determination or final adverse determination.
(3) Within one business day after making the decision
to terminate the external review and make a decision to
reverse the adverse determination or final adverse
determination under item (2) of this subsection (f), the
independent review organization shall notify the health
carrier, the covered person and, if applicable, the covered
person's authorized representative, of its decision to

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reverse the adverse determination.
(g) Upon receipt of the information from the health carrier
or its utilization review organization, the assigned
independent review organization shall review all of the
information and documents and any other information submitted
in writing to the independent review organization by the
covered person and the covered person's authorized
representative.
(h) Upon receipt of any information submitted by the
covered person or the covered person's authorized
representative, the independent review organization shall
forward the information to the health carrier within 1 business
day.
(1) Upon receipt of the information, if any, the health
carrier may reconsider its adverse determination or final
adverse determination that is the subject of the external
review.
(2) Reconsideration by the health carrier of its
adverse determination or final adverse determination shall
not delay or terminate the external review.
(3) The external review may only be terminated if the
health carrier decides, upon completion of its
reconsideration, to reverse its adverse determination or
final adverse determination and provide coverage or
payment for the health care service that is the subject of
the adverse determination or final adverse determination.

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In such cases, the following provisions shall apply:
(A) Within one business day after making the
decision to reverse its adverse determination or final
adverse determination, the health carrier shall notify
the covered person and if applicable, the covered
person's authorized representative, and the assigned
independent review organization in writing of its
decision.
(B) Upon notice from the health carrier that the
health carrier has made a decision to reverse its
adverse determination or final adverse determination,
the assigned independent review organization shall
terminate the external review.
(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,
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

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carrier, 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;
(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
(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) 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:

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(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
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, 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 health carrier, the covered person

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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 health carrier to
conduct the external review;
(C) the time period during which the external
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.
(2) For reviews of experimental or investigational
treatments, the notice shall include the following
information:

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(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
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

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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) 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 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.
Section 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 health carrier either orally or in writing:
(1) immediately after the date of receipt of a notice

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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 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) 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
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

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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 and shall be subject to all applicable
provisions of this Act.
(c) Upon determining that a request meets the requirements
of subsections (b) and (c) of Section 20, the 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) Immediately upon assigning an independent review
organization to perform an expedited external review, but
in no case more than 24 hours after assigning the
independent review organization, the health carrier or its
designee utilization review organization shall provide or

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transmit all necessary documents and information
considered in making the 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 health
carrier, the covered person and, if applicable, the covered
person's authorized representative of its decision to
reverse the adverse determination.
(d) In addition to the documents and information provided
by the health carrier or its utilization review organization
and any documents and information provided by the covered
person and the covered person's authorized representative, the
independent review organization shall consider information as
required by subsection (i) of Section 35 of this Act in
reaching a decision.

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(e) As expeditiously as the covered person's medical
condition or circumstances requires, but in no event more than
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 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 grievance process as set forth
in the Managed Care Reform and Patient Rights Act.
(g) Upon receipt of notice of a decision reversing the
final adverse determination, the health carrier shall
immediately approve the coverage that was the subject of the
final adverse determination.
(h) Within 48 hours after the date of providing the notice
required in item (2) of subsection (e), the assigned
independent review organization shall provide written
confirmation of the decision to 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.

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(i) An expedited external review may not be provided for
retrospective adverse or final adverse determinations.
Section 45. Binding nature of external review decision. An
external review decision is binding on the health carrier. An
external review decision is binding on the covered person
except to the extent the covered person has other remedies
available under applicable federal or State law. A covered
person or the covered person's authorized representative may
not file a subsequent request for external review involving the
same adverse determination or final adverse determination for
which the covered person has already received an external
review decision pursuant to this Act.
Section 50. Approval of independent review organizations.
(a) The Director shall approve independent review
organizations eligible to be assigned to conduct external
reviews under this Act.
(b) In order to be eligible for approval by the Director
under this Section to conduct external reviews under this Act
an independent review organization:
(1) except as otherwise provided in this Section, shall
be accredited by a nationally recognized private
accrediting entity that the Director has determined has
independent review organization accreditation standards
that are equivalent to or exceed the minimum qualifications

HB3923 Enrolled - 32 - LRB096 08394 RPM 18506 b
for independent review; and
(2) shall submit an application for approval in
accordance with subsection (d) of this Section.
(c) The Director shall develop an application form for
initially approving and for reapproving independent review
organizations to conduct external reviews.
(d) Any independent review organization wishing to be
approved to conduct external reviews under this Act shall
submit the application form and include with the form all
documentation and information necessary for the Director to
determine if the independent review organization satisfies the
minimum qualifications established under this Act. The
Director may:
(1) approve independent review organizations that are
not accredited by a nationally recognized private
accrediting entity if there are no acceptable nationally
recognized private accrediting entities providing
independent review organization accreditation; and
(2) by rule establish an application fee that
independent review organizations shall submit to the
Director with an application for approval and renewing.
(e) An approval is effective for 2 years, unless the
Director determines before its expiration that the independent
review organization is not satisfying the minimum
qualifications established under this Act.
(f) Whenever the Director determines that an independent

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review organization has lost its accreditation or no longer
satisfies the minimum requirements established under this Act,
the Director shall terminate the approval of the independent
review organization and remove the independent review
organization from the list of independent review organizations
approved to conduct external reviews under this Act that is
maintained by the Director.
(g) The Director shall maintain and periodically update a
list of approved independent review organizations.
(h) The Director may promulgate regulations to carry out
the provisions of this Section.
Section 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

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independent review organization and suitable matching
of reviewers to specific cases and that the independent
review organization employs or contracts with an
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,

HB3923 Enrolled - 35 - LRB096 08394 RPM 18506 b
and records information related to external reviews and
provides appropriate instructions; and
(3) an agreement to maintain and provide to the
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

HB3923 Enrolled - 36 - LRB096 08394 RPM 18506 b
competence or moral character.
(c) In addition to the requirements set forth in subsection
(a), an independent review organization may not own or control,
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

HB3923 Enrolled - 37 - LRB096 08394 RPM 18506 b
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
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.
Section 60. Hold harmless for independent review
organizations. No independent review organization or clinical

HB3923 Enrolled - 38 - LRB096 08394 RPM 18506 b
reviewer working on behalf of an independent review
organization or an employee, agent or contractor of an
independent review organization shall be liable for damages to
any person for any opinions rendered or acts or omissions
performed within the scope of the organization's or person's
duties under the law during or upon completion of an external
review conducted pursuant to this Act, unless the opinion was
rendered or act or omission performed in bad faith or involved
gross negligence.
Section 65. External review reporting requirements.
(a) Each health carrier shall maintain written records in
the aggregate on all requests for external review for each
calendar year and submit a report to the Director in the format
specified by the Director by March 1 of each year.
(b) The report shall include in the aggregate:
(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;

HB3923 Enrolled - 39 - LRB096 08394 RPM 18506 b
(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
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);

HB3923 Enrolled - 40 - LRB096 08394 RPM 18506 b
(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
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.
Section 70. Funding of external review. The health carrier
shall be solely responsible for paying the cost of external
reviews conducted by independent review organizations.
Section 75. Disclosure requirements.
(a) Each health carrier shall include a description of the

HB3923 Enrolled - 41 - LRB096 08394 RPM 18506 b
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
determination with the 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.
Section 90. The Illinois Insurance Code is amended by
changing Section 155.36 and by adding Sections 359b and 359c as
follows:
(215 ILCS 5/155.36)
Sec. 155.36. Managed Care Reform and Patient Rights Act.
Insurance companies that transact the kinds of insurance
authorized under Class 1(b) or Class 2(a) of Section 4 of this
Code shall comply with Sections 45 and Section 85 and the
definition of the term "emergency medical condition" in Section
10 of the Managed Care Reform and Patient Rights Act.

HB3923 Enrolled - 42 - LRB096 08394 RPM 18506 b
(Source: P.A. 91-617, eff. 1-1-00.)
(215 ILCS 5/359b new)
Sec. 359b. Committee to create a uniform small employer
group-health status questionnaire and individual health
statement.
(a) For the purposes of this Section:
"Employee health-status questionnaire" means a
questionnaire that poses questions about an individual
employee's or covered dependent's health history and that is to
be completed by the individual employee or covered dependent of
a small employer that seeks health insurance coverage from a
small employer carrier.
"Health benefit plan", "small employer", and "small
employer carrier" shall have the meaning given the terms in the
Small Employer Health Insurance Rating Act.
"Individual health insurance coverage" and "individual
market" shall have the meaning given the terms in the Illinois
Health Insurance Portability and Accountability Act.
(b) A committee is established in the Department consisting
of 11 members, including the Director or the Director's
designee, who are appointed by the Director. The Director shall
appoint to the committee 5 representatives as recommended by
the Illinois Insurance Association, Illinois Life Insurance
Council, Professional Independent Insurance Agents of
Illinois, Illinois Association of Health Underwriters,

HB3923 Enrolled - 43 - LRB096 08394 RPM 18506 b
Illinois Chamber of Commerce, Illinois Manufacturers
Association, Illinois Retail Merchants Association, and
National Federation of Independent Businesses and 5 consumer
representatives. The Director or the Director's designee shall
serve as chairperson of the committee.
(c) The committee shall develop a uniform employee
health-status questionnaire to simplify the health insurance
application process for small employers. The committee shall
study employee-health status questionnaires currently used by
major small employer carriers in this State and consolidate the
questionnaires into a uniform questionnaire. The questionnaire
shall be designed to permit its use both as a written document
and through electronic or other alternative delivery formats.
A uniform employee health-status questionnaire shall allow
small employers that are required to provide information
regarding their employees to a small employer carrier when
applying for a small employer group health insurance policy to
use a standardized questionnaire that small employer carriers
shall be required to use. The development of the uniform
employee health-status questionnaire is intended to relieve
small employers of the burden of completing separate
application forms for each small employer carrier with which
the employer applies for insurance or from which the employer
seeks information regarding such matters as rates, coverage,
and availability. The use of the uniform employee health-status
questionnaire by small employer carriers and small employers

HB3923 Enrolled - 44 - LRB096 08394 RPM 18506 b
shall be mandatory.
(d) On or before July 1, 2010, the committee shall develop
the uniform employee health-status questionnaire for adoption
by the Department. Beginning January 1, 2011, a small employer
carrier shall use the questionnaire for all small employer
groups for which it requires employees and their covered
dependents to complete questionnaires.
(e) The Director, as needed, may reconvene the committee to
consider whether changes are necessary to the uniform employee
health status questionnaire. If the committee determines that
changes to the questionnaire are necessary, then the Director
may adopt revisions to the questionnaire as recommended by the
committee. Small employer carriers shall use the revised
questionnaire beginning 90 days after the Director adopts any
revision.
(f) Nothing in this Section shall be construed to limit or
restrict a small employer carrier's ability to appropriately
rate risk under a small employer health benefit plan.
(g) On or before July 1, 2010, the committee shall develop
a standard individual market health statement to simplify the
health insurance application process for individuals. The
committee shall study health statements currently used by major
carriers in this State who offer individual health insurance
coverage and consolidate the statements into a standard
individual market health statement. The standard individual
market health statement shall be designed to permit its use

HB3923 Enrolled - 45 - LRB096 08394 RPM 18506 b
both as a written document and through electronic or other
alternative delivery formats. For purposes of the individual
market health statement, the Director may, but shall not be
required to, establish a committee distinct from that formed to
develop an application for small employers. In that event, the
composition of the committee shall be as prescribed in
subsection (b) of this Section, although individual
participants may change.
(h) Beginning January 1, 2011, all carriers who offer
individual health insurance coverage and evaluate the health
status of individuals shall use the standard individual market
health statement.
(i) The Director, as needed, may reconvene the committee to
consider whether changes are necessary to the standard
individual market health statement. If the committee
determines that changes to the statement are necessary, the
Director may adopt revisions to the statement as recommended by
the committee. All carriers who offer individual health
insurance coverage shall use the revised statement beginning 90
days after the Director adopts any revision.
(j) Nothing in this Section shall prevent a carrier from
using health information after enrollment for the purpose of
providing services or arranging for the provision of services
under a health benefit plan or a policy of individual health
insurance coverage.
(k) Nothing in this Section shall be construed to limit or

HB3923 Enrolled - 46 - LRB096 08394 RPM 18506 b
restrict a health carrier's ability to appropriately rate risk,
refuse to issue or renew coverage, or otherwise rescind,
terminate, or restrict coverage under a health benefit plan or
a policy of individual health insurance coverage or conduct
further review of the information submitted on the statement by
contacting an individual, the individual's health care
provider, or any other entity for additional health status
related information.
(l) Committee members are not eligible for compensation but
may receive reimbursement of expenses.
(215 ILCS 5/359c new)
Sec. 359c. Accident and health expense reporting.
(a) Beginning January 1, 2011 and every 6 months
thereafter, any carrier providing a group or individual major
medical policy of accident or health insurance shall prepare
and provide to the Department of Insurance a statement of the
aggregate administrative expenses of the carrier, based on the
premiums earned in the immediately preceding 6-month period on
the accident or health insurance business of the carrier. The
semi-annual statements shall be filed on or before July 31 for
the preceding 6-month period ending June 30 and on or before
February 1 for the preceding 6-month period ending December 31.
The statements shall itemize and separately detail all of the
following information with respect to the carrier's accident or
health insurance business:

HB3923 Enrolled - 47 - LRB096 08394 RPM 18506 b
(1) the amount of premiums earned by the carrier both
before and after any costs related to the carrier's
purchase of reinsurance coverage;
(2) the total amount of claims for losses paid by the
carrier both before and after any reimbursement from
reinsurance coverage including any costs incurred related
to:
(A) disease, case, or chronic care management
programs;
(B) wellness and health education programs;
(C) fraud prevention;
(D) maintaining provider networks and provider
credentialing;
(E) health information technology for personal
electronic health records; and
(F) utilization review and utilization management;
(3) the amount of any losses incurred by the carrier
but not reported to the carrier in the current or prior
reporting period;
(4) the amount of costs incurred by the carrier for
State fees and federal and State taxes including:
(A) any high risk pool and guaranty fund
assessments levied on the carrier by the State; and
(B) any regulatory compliance costs including
State fees for form and rate filings, licensures,
market conduct exams, and financial reports;

HB3923 Enrolled - 48 - LRB096 08394 RPM 18506 b
(5) the amount of costs incurred by the carrier for
reinsurance coverage;
(6) the amount of costs incurred by the carrier that
are related to the carrier's payment of marketing expenses
including commissions; and
(7) any other administrative expenses incurred by the
carrier.
(b) The information provided pursuant to subsection (a) of
this Section shall be separately aggregated for the following
lines of major medical insurance:
(1) individually underwritten;
(2) groups of 2 to 25 members;
(3) groups of 26 to 50 members;
(4) groups of 51 or more members.
(c) The Department shall make the submitted information
publicly available on the Department's website or such other
media as appropriate in a form useful for consumers.
Section 95. The Managed Care Reform and Patient Rights Act
is amended by changing Sections 40 and 45 as follows:
(215 ILCS 134/40)
Sec. 40. Access to specialists.
(a) All health care plans that require each enrollee to
select a health care provider for any purpose including
coordination of care shall permit an enrollee to choose any

HB3923 Enrolled - 49 - LRB096 08394 RPM 18506 b
available primary care physician licensed to practice medicine
in all its branches participating in the health care plan for
that purpose. The health care plan shall provide the enrollee
with a choice of licensed health care providers who are
accessible and qualified. Nothing in this Act shall be
construed to prohibit a health care plan from requiring a
health care provider to meet the health care plan's criteria in
order to coordinate access to health care.
(b) A health care plan shall establish a procedure by which
an enrollee who has a condition that requires ongoing care from
a specialist physician or other health care provider may apply
for a standing referral to a specialist physician or other
health care provider if a referral to a specialist physician or
other health care provider is required for coverage. The
application shall be made to the enrollee's primary care
physician. This procedure for a standing referral must specify
the necessary criteria and conditions that must be met in order
for an enrollee to obtain a standing referral. A standing
referral shall be effective for the period necessary to provide
the referred services or one year, except in the event of
termination of a contract or policy in which case Section 25 on
transition of services shall apply, if applicable. A primary
care physician may renew and re-renew a standing referral.
(c) The enrollee may be required by the health care plan to
select a specialist physician or other health care provider who
has a referral arrangement with the enrollee's primary care

HB3923 Enrolled - 50 - LRB096 08394 RPM 18506 b
physician or to select a new primary care physician who has a
referral arrangement with the specialist physician or other
health care provider chosen by the enrollee. If a health care
plan requires an enrollee to select a new physician under this
subsection, the health care plan must provide the enrollee with
both options provided in this subsection. When a participating
specialist with a referral arrangement is not available, the
primary care physician, in consultation with the enrollee,
shall arrange for the enrollee to have access to a qualified
participating health care provider, and the enrollee shall be
allowed to stay with his or her primary care physician. If a
secondary referral is necessary, the specialist physician or
other health care provider shall advise the primary care
physician. The primary care physician shall be responsible for
making the secondary referral. In addition, the health care
plan shall require the specialist physician or other health
care provider to provide regular updates to the enrollee's
primary care physician.
(d) When the type of specialist physician or other health
care provider needed to provide ongoing care for a specific
condition is not represented in the health care plan's provider
network, the primary care physician shall arrange for the
enrollee to have access to a qualified non-participating health
care provider within a reasonable distance and travel time at
no additional cost beyond what the enrollee would otherwise pay
for services received within the network. The referring

HB3923 Enrolled - 51 - LRB096 08394 RPM 18506 b
physician shall notify the plan when a referral is made outside
the network.
(e) The enrollee's primary care physician shall remain
responsible for coordinating the care of an enrollee who has
received a standing referral to a specialist physician or other
health care provider. If a secondary referral is necessary, the
specialist physician or other health care provider shall advise
the primary care physician. The primary care physician shall be
responsible for making the secondary referral. In addition, the
health care plan shall require the specialist physician or
other health care provider to provide regular updates to the
enrollee's primary care physician.
(f) If an enrollee's application for any referral is
denied, an enrollee may appeal the decision through the health
care plan's external independent review process as provided by
the Illinois Health Carrier External Review Act in accordance
with subsection (f) of Section 45 of this Act.
(g) Nothing in this Act shall be construed to require an
enrollee to select a new primary care physician when no
referral arrangement exists between the enrollee's primary
care physician and the specialist selected by the enrollee and
when the enrollee has a long-standing relationship with his or
her primary care physician.
(h) In promulgating rules to implement this Act, the
Department shall define "standing referral" and "ongoing
course of treatment".

HB3923 Enrolled - 52 - LRB096 08394 RPM 18506 b
(Source: P.A. 91-617, eff. 1-1-00.)
(215 ILCS 134/45)
Sec. 45. Health care services appeals, complaints, and
external independent reviews.
(a) A health care plan shall establish and maintain an
appeals procedure as outlined in this Act. Compliance with this
Act's appeals procedures shall satisfy a health care plan's
obligation to provide appeal procedures under any other State
law or rules. All appeals of a health care plan's
administrative determinations and complaints regarding its
administrative decisions shall be handled as required under
Section 50.
(b) When an appeal concerns a decision or action by a
health care plan, its employees, or its subcontractors that
relates to (i) health care services, including, but not limited
to, procedures or treatments, for an enrollee with an ongoing
course of treatment ordered by a health care provider, the
denial of which could significantly increase the risk to an
enrollee's health, or (ii) a treatment referral, service,
procedure, or other health care service, the denial of which
could significantly increase the risk to an enrollee's health,
the health care plan must allow for the filing of an appeal
either orally or in writing. Upon submission of the appeal, a
health care plan must notify the party filing the appeal, as
soon as possible, but in no event more than 24 hours after the

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submission of the appeal, of all information that the plan
requires to evaluate the appeal. The health care plan shall
render a decision on the appeal within 24 hours after receipt
of the required information. The health care plan shall notify
the party filing the appeal and the enrollee, enrollee's
primary care physician, and any health care provider who
recommended the health care service involved in the appeal of
its decision orally followed-up by a written notice of the
determination.
(c) For all appeals related to health care services
including, but not limited to, procedures or treatments for an
enrollee and not covered by subsection (b) above, the health
care plan shall establish a procedure for the filing of such
appeals. Upon submission of an appeal under this subsection, a
health care plan must notify the party filing an appeal, within
3 business days, of all information that the plan requires to
evaluate the appeal. The health care plan shall render a
decision on the appeal within 15 business days after receipt of
the required information. The health care plan shall notify the
party filing the appeal, the enrollee, the enrollee's primary
care physician, and any health care provider who recommended
the health care service involved in the appeal orally of its
decision followed-up by a written notice of the determination.
(d) An appeal under subsection (b) or (c) may be filed by
the enrollee, the enrollee's designee or guardian, the
enrollee's primary care physician, or the enrollee's health

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care provider. A health care plan shall designate a clinical
peer to review appeals, because these appeals pertain to
medical or clinical matters and such an appeal must be reviewed
by an appropriate health care professional. No one reviewing an
appeal may have had any involvement in the initial
determination that is the subject of the appeal. The written
notice of determination required under subsections (b) and (c)
shall include (i) clear and detailed reasons for the
determination, (ii) the medical or clinical criteria for the
determination, which shall be based upon sound clinical
evidence and reviewed on a periodic basis, and (iii) in the
case of an adverse determination, the procedures for requesting
an external independent review as provided by the Illinois
Health Carrier External Review Act under subsection (f).
(e) If an appeal filed under subsection (b) or (c) is
denied for a reason including, but not limited to, the service,
procedure, or treatment is not viewed as medically necessary,
denial of specific tests or procedures, denial of referral to
specialist physicians or denial of hospitalization requests or
length of stay requests, any involved party may request an
external independent review as provided by the Illinois Health
Carrier External Review Act under subsection (f) of the adverse
determination.
(f) Until July 1, 2013, if an external independent review
decision made pursuant to the Illinois Health Carrier External
Review Act upholds a determination adverse to the covered

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person, the covered person has the right to appeal the final
decision to the Department; if the external review decision is
found by the Director to have been arbitrary and capricious,
then the Director, with consultation from a licensed medical
professional, may overturn the external review decision and
require the health carrier to pay for the health care service
or treatment; such decision, if any, shall be made solely on
the legal or medical merits of the claim. If an external review
decision is overturned by the Director pursuant to this Section
and the health carrier so requests, then the Director shall
assign a new independent review organization to reconsider the
overturned decision. The new independent review organization
shall follow subsection (d) of Section 40 of the Health Carrier
External Review Act in rendering a decision. External
independent review.
(1) The party seeking an external independent review
shall so notify the health care plan. The health care plan
shall seek to resolve all external independent reviews in
the most expeditious manner and shall make a determination
and provide notice of the determination no more than 24
hours after the receipt of all necessary information when a
delay would significantly increase the risk to an
enrollee's health or when extended health care services for
an enrollee undergoing a course of treatment prescribed by
a health care provider are at issue.
(2) Within 30 days after the enrollee receives written

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notice of an adverse determination, if the enrollee decides
to initiate an external independent review, the enrollee
shall send to the health care plan a written request for an
external independent review, including any information or
documentation to support the enrollee's request for the
covered service or claim for a covered service.
(3) Within 30 days after the health care plan receives
a request for an external independent review from an
enrollee, the health care plan shall:
(A) provide a mechanism for joint selection of an
external independent reviewer by the enrollee, the
enrollee's physician or other health care provider,
and the health care plan; and
(B) forward to the independent reviewer all
medical records and supporting documentation
pertaining to the case, a summary description of the
applicable issues including a statement of the health
care plan's decision, the criteria used, and the
medical and clinical reasons for that decision.
(4) Within 5 days after receipt of all necessary
information, the independent reviewer shall evaluate and
analyze the case and render a decision that is based on
whether or not the health care service or claim for the
health care service is medically appropriate. The decision
by the independent reviewer is final. If the external
independent reviewer determines the health care service to

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be medically appropriate, the health care plan shall pay
for the health care service.
(5) The health care plan shall be solely responsible
for paying the fees of the external independent reviewer
who is selected to perform the review.
(6) An external independent reviewer who acts in good
faith shall have immunity from any civil or criminal
liability or professional discipline as a result of acts or
omissions with respect to any external independent review,
unless the acts or omissions constitute wilful and wanton
misconduct. For purposes of any proceeding, the good faith
of the person participating shall be presumed.
(g) (7) Future contractual or employment action by the
health care plan regarding the patient's physician or other
health care provider shall not be based solely on the
physician's or other health care provider's participation
in health care services appeals, complaints, or external
independent reviews under the Illinois Health Carrier
External Review Act this procedure.
(8) For the purposes of this Section, an external
independent reviewer shall:
(A) be a clinical peer;
(B) have no direct financial interest in
connection with the case; and
(C) have not been informed of the specific identity
of the enrollee.

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(h) (g) Nothing in this Section shall be construed to
require a health care plan to pay for a health care service not
covered under the enrollee's certificate of coverage or policy.
(Source: P.A. 91-617, eff. 1-1-00.)
Section 96. No acceleration or delay. Where this Act makes
changes in a statute that is represented in this Act by text
that is not yet or no longer in effect (for example, a Section
represented by multiple versions), the use of that text does
not accelerate or delay the taking effect of (i) the changes
made by this Act or (ii) provisions derived from any other
Public Act.
Section 97. Severability. The provisions of this Act are
severable under Section 1.31 of the Statute on Statutes.
Section 99. Effective date. This Act takes effect January
1, 2010, except that the changes to Section 155.36 of the
Illinois Insurance Code and Sections 40 and 45 of the Managed
Care Reform and Patient Rights Act and the Health Carrier