HB3923 Enrolled LRB096 08394 RPM 18506 b
1		AN ACT concerning insurance.
2		Be it enacted by the People of the State of Illinois,
3		represented in the General Assembly:
4		Section 1. Short title. This Act may be cited as the Health
5		Carrier External Review Act.
6		Section 5. Purpose and intent. The purpose of this Act is
7		to provide uniform standards for the establishment and
8		maintenance of external review procedures to assure that
9		covered persons have the opportunity for an independent review
10		of an adverse determination or final adverse determination, as
11		defined in this Act.
12		Section 10. Definitions. For the purposes of this Act:
13		"Adverse determination" means a determination by a health
14		carrier or its designee utilization review organization that an
15		admission, availability of care, continued stay, or other
16		health care service that is a covered benefit has been reviewed
17		and, based upon the information provided, does not meet the
18		health carrier's requirements for medical necessity,
19		appropriateness, health care setting, level of care, or
20		effectiveness, and the requested service or payment for the
21		service is therefore denied, reduced, or terminated.
22		"Authorized representative" means:

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

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

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

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

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

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

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1		Patient Rights Act.
2		Section 15. Applicability and scope.
3		(a) Except as provided in subsection (b) of this Section,
4		this Act shall apply to all health carriers.
5		(b) The provisions of this Act shall not apply to a policy
6		or certificate that provides coverage only for a specified
7		disease, specified accident or accident-only coverage, credit,
8		dental, disability income, hospital indemnity, long-term care
9		insurance as defined by Article XIXA of the Illinois Insurance
10		Code, vision care, or any other limited supplemental benefit; a
11		Medicare supplement policy of insurance as defined by the
12		Director by regulation; coverage under a plan through Medicare,
13		Medicaid, or the federal employees health benefits program; any
14		coverage issued under Chapter 55 of Title 10, U.S. Code and any
15		coverage issued as supplement to that coverage; any coverage
16		issued as supplemental to liability insurance, workers'
17		compensation, or similar insurance; automobile medical-payment
18		insurance or any insurance under which benefits are payable
19		with or without regard to fault, whether written on a group
20		blanket or individual basis.
21		Section 20. Notice of right to external review.
22		(a) At the same time the health carrier sends written
23		notice of a covered person's right to appeal a coverage
24		decision upon an adverse determination or a final adverse

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

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1		Managed Care Reform and Patient Rights Act, or (C) a
2		standard external review as established in this Act, would
3		seriously jeopardize the life or health of the covered
4		person or would jeopardize the covered person's ability to
5		regain maximum function, then the covered person or the
6		covered person's authorized representative may file a
7		request for an expedited external review.
8		(2) The covered person or the covered person's
9		authorized representative may file a request for an
10		expedited external review at the same time the covered
11		person or the covered person's authorized representative
12		files a request for an expedited internal appeal involving
13		an adverse determination as set forth in the Managed Care
14		Reform and Patient Rights Act if the adverse determination
15		involves a denial of coverage based on a determination that
16		the recommended or requested health care service or
17		treatment is experimental or investigational and the
18		covered person's health care provider certifies in writing
19		that the recommended or requested health care service or
20		treatment that is the subject of the adverse determination
21		would be significantly less effective if not promptly
22		initiated. The independent review organization assigned to
23		conduct the expedited external review will determine
24		whether the covered person shall be required to complete
25		the expedited review of the grievance prior to conducting
26		the expedited external review.

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

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

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

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

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1		(1) the individual is or was a covered person in the
2		health benefit plan at the time the health care service was
3		requested or at the time the health care service was
4		provided;
5		(2) the health care service that is the subject of the
6		adverse determination or the final adverse determination
7		is a covered service under the covered person's health
8		benefit plan, but the health carrier has determined that
9		the health care service is not covered because it does not
10		meet the health carrier's requirements for medical
11		necessity, appropriateness, health care setting, level of
12		care, or effectiveness;
13		(3) the covered person has exhausted the health
14		carrier's internal grievance process as set forth in this
15		Act;
16		(4) for appeals relating to a determination based on
17		treatment being experimental or investigational, the
18		requested health care service or treatment that is the
19		subject of the adverse determination or final adverse
20		determination is a covered benefit under the covered
21		person's health benefit plan except for the health
22		carrier's determination that the service or treatment is
23		experimental or investigational for a particular medical
24		condition and is not explicitly listed as an excluded
25		benefit under the covered person's health benefit plan with
26		the health carrier and that the covered person's health

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1		care provider, who is a physician licensed to practice
2		medicine in all its branches, has certified that one of the
3		following situations is applicable:
4		(A) standard health care services or treatments
5		have not been effective in improving the condition of
6		the covered person;
7		(B) standard health care services or treatments
8		are not medically appropriate for the covered person;
9		(C) there is no available standard health care
10		service or treatment covered by the health carrier that
11		is more beneficial than the recommended or requested
12		health care service or treatment;
13		(D) the health care service or treatment is likely
14		to be more beneficial to the covered person, in the
15		health care provider's opinion, than any available
16		standard health care services or treatments; or
17		(E) that scientifically valid studies using
18		accepted protocols demonstrate that the health care
19		service or treatment requested is likely to be more
20		beneficial to the covered person than any available
21		standard health care services or treatments; and
22		(5) the covered person has provided all the information
23		and forms required to process an external review, as
24		specified in this Act.
25		(c) Within one business day after completion of the
26		preliminary review, the health carrier shall notify the covered

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

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

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

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

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

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

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1		(A) the recommended or requested health care
2		service or treatment has been approved by the federal
3		Food and Drug Administration, if applicable, for the
4		condition;
5		(B) medical or scientific evidence or
6		evidence-based standards demonstrate that the expected
7		benefits of the recommended or requested health care
8		service or treatment is more likely than not to be
9		beneficial to the covered person than any available
10		standard health care service or treatment and the
11		adverse risks of the recommended or requested health
12		care service or treatment would not be substantially
13		increased over those of available standard health care
14		services or treatments; or
15		(C) the terms of coverage under the covered
16		person's health benefit plan with the health carrier to
17		ensure that the health care service or treatment that
18		is the subject of the opinion is experimental or
19		investigational would otherwise be covered under the
20		terms of coverage of the covered person's health
21		benefit plan with the health carrier.
22		(j) Within 5 days after the date of receipt of all
23		necessary information, the assigned independent review
24		organization shall provide written notice of its decision to
25		uphold or reverse the adverse determination or the final
26		adverse determination to the health carrier, the covered person

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

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1		(A) a description of the covered person's medical
2		condition;
3		(B) a description of the indicators relevant to
4		whether there is sufficient evidence to demonstrate
5		that the recommended or requested health care service
6		or treatment is more likely than not to be more
7		beneficial to the covered person than any available
8		standard health care services or treatments and the
9		adverse risks of the recommended or requested health
10		care service or treatment would not be substantially
11		increased over those of available standard health care
12		services or treatments;
13		(C) a description and analysis of any medical or
14		scientific evidence considered in reaching the
15		opinion;
16		(D) a description and analysis of any
17		evidence-based standards;
18		(E) whether the recommended or requested health
19		care service or treatment has been approved by the
20		federal Food and Drug Administration, for the
21		condition;
22		(F) whether medical or scientific evidence or
23		evidence-based standards demonstrate that the expected
24		benefits of the recommended or requested health care
25		service or treatment is more likely than not to be more
26		beneficial to the covered person than any available

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1		standard health care service or treatment and the
2		adverse risks of the recommended or requested health
3		care service or treatment would not be substantially
4		increased over those of available standard health care
5		services or treatments; and
6		(G) the written opinion of the clinical reviewer,
7		including the reviewer's recommendation as to whether
8		the recommended or requested health care service or
9		treatment should be covered and the rationale for the
10		reviewer's recommendation.
11		(3) In reaching a decision, the assigned independent
12		review organization is not bound by any decisions or
13		conclusions reached during the health carrier's
14		utilization review process or the health carrier's
15		internal grievance or appeals process.
16		(4) Upon receipt of a notice of a decision reversing
17		the adverse determination or final adverse determination,
18		the health carrier immediately shall approve the coverage
19		that was the subject of the adverse determination or final
20		adverse determination.
21		Section 40. Expedited external review.
22		(a) A covered person or a covered person's authorized
23		representative may file a request for an expedited external
24		review with the health carrier either orally or in writing:
25		(1) immediately after the date of receipt of a notice

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1		prior to a final adverse determination as provided by
2		subsection (b) of Section 20 of this Act;
3		(2) immediately after the date of receipt of a notice a
4		final adverse determination as provided by subsection (c)
5		of Section 20 of this Act; or
6		(3) if a health carrier fails to provide a decision on
7		request for an expedited internal appeal within 48 hours as
8		provided by item (2) of Section 30 of this Act.
9		(b) Immediately upon receipt of the request for an
10		expedited external review as provided under subsections (b) and
11		(c) of Section 20, the health carrier shall determine whether
12		the request meets the reviewability requirements set forth in
13		items (1), (2), and (4) of subsection (b) of Section 35. In
14		such cases, the following provisions shall apply:
15		(1) The health carrier shall immediately notify the
16		covered person and, if applicable, the covered person's
17		authorized representative of its eligibility
18		determination.
19		(2) The notice of initial determination shall include a
20		statement informing the covered person and, if applicable,
21		the covered person's authorized representative that a
22		health carrier's initial determination that an external
23		review request is ineligible for review may be appealed to
24		the Director.
25		(3) The Director may determine that a request is
26		eligible for expedited external review notwithstanding a

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1		health carrier's initial determination that the request is
2		ineligible and require that it be referred for external
3		review.
4		(4) In making a determination under item (3) of this
5		subsection (b), the Director's decision shall be made in
6		accordance with the terms of the covered person's health
7		benefit plan and shall be subject to all applicable
8		provisions of this Act.
9		(c) Upon determining that a request meets the requirements
10		of subsections (b) and (c) of Section 20, the health carrier
11		shall immediately assign an independent review organization
12		from the list of approved independent review organizations
13		compiled and maintained by the Director to conduct the
14		expedited review. In such cases, the following provisions shall
15		apply:
16		(1) The assignment of an approved independent review
17		organization to conduct an external review in accordance
18		with this Section shall be made from those approved
19		independent review organizations qualified to conduct
20		external review as required by Sections 50 and 55 of this
21		Act.
22		(2) Immediately upon assigning an independent review
23		organization to perform an expedited external review, but
24		in no case more than 24 hours after assigning the
25		independent review organization, the health carrier or its
26		designee utilization review organization shall provide or

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

HB3923 Enrolled - 30 - LRB096 08394 RPM 18506 b
1		(e) As expeditiously as the covered person's medical
2		condition or circumstances requires, but in no event more than
3		2 business days after the receipt of all pertinent information,
4		the assigned independent review organization shall:
5		(1) make a decision to uphold or reverse the final
6		adverse determination; and
7		(2) notify the health carrier, the covered person, the
8		covered person's health care provider, and if applicable,
9		the covered person's authorized representative, of the
10		decision.
11		(f) In reaching a decision, the assigned independent review
12		organization is not bound by any decisions or conclusions
13		reached during the health carrier's utilization review process
14		or the health carrier's internal grievance process as set forth
15		in the Managed Care Reform and Patient Rights Act.
16		(g) Upon receipt of notice of a decision reversing the
17		final adverse determination, the health carrier shall
18		immediately approve the coverage that was the subject of the
19		final adverse determination.
20		(h) Within 48 hours after the date of providing the notice
21		required in item (2) of subsection (e), the assigned
22		independent review organization shall provide written
23		confirmation of the decision to the health carrier, the covered
24		person, and if applicable, the covered person's authorized
25		representative including the information set forth in
26		subsection (j) of Section 35 of this Act as applicable.

HB3923 Enrolled - 31 - LRB096 08394 RPM 18506 b
1		(i) An expedited external review may not be provided for
2		retrospective adverse or final adverse determinations.
3		Section 45. Binding nature of external review decision. An
4		external review decision is binding on the health carrier. An
5		external review decision is binding on the covered person
6		except to the extent the covered person has other remedies
7		available under applicable federal or State law. A covered
8		person or the covered person's authorized representative may
9		not file a subsequent request for external review involving the
10		same adverse determination or final adverse determination for
11		which the covered person has already received an external
12		review decision pursuant to this Act.
13		Section 50. Approval of independent review organizations.
14		(a) The Director shall approve independent review
15		organizations eligible to be assigned to conduct external
16		reviews under this Act.
17		(b) In order to be eligible for approval by the Director
18		under this Section to conduct external reviews under this Act
19		an independent review organization:
20		(1) except as otherwise provided in this Section, shall
21		be accredited by a nationally recognized private
22		accrediting entity that the Director has determined has
23		independent review organization accreditation standards
24		that are equivalent to or exceed the minimum qualifications

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

HB3923 Enrolled - 33 - LRB096 08394 RPM 18506 b
1		review organization has lost its accreditation or no longer
2		satisfies the minimum requirements established under this Act,
3		the Director shall terminate the approval of the independent
4		review organization and remove the independent review
5		organization from the list of independent review organizations
6		approved to conduct external reviews under this Act that is
7		maintained by the Director.
8		(g) The Director shall maintain and periodically update a
9		list of approved independent review organizations.
10		(h) The Director may promulgate regulations to carry out
11		the provisions of this Section.
12		Section 55. Minimum qualifications for independent review
13		organizations.
14		(a) To be approved to conduct external reviews, an
15		independent review organization shall have and maintain
16		written policies and procedures that govern all aspects of both
17		the standard external review process and the expedited external
18		review process set forth in this Act that include, at a
19		minimum:
20		(1) a quality assurance mechanism that ensures that:
21		(A) external reviews are conducted within the
22		specified timeframes and required notices are provided
23		in a timely manner;
24		(B) selection of qualified and impartial clinical
25		reviewers to conduct external reviews on behalf of the

HB3923 Enrolled - 34 - LRB096 08394 RPM 18506 b
1		independent review organization and suitable matching
2		of reviewers to specific cases and that the independent
3		review organization employs or contracts with an
4		adequate number of clinical reviewers to meet this
5		objective;
6		(C) for adverse determinations involving
7		experimental or investigational treatments, in
8		assigning clinical reviewers, the independent review
9		organization selects physicians or other health care
10		professionals who, through clinical experience in the
11		past 3 years, are experts in the treatment of the
12		covered person's condition and knowledgeable about the
13		recommended or requested health care service or
14		treatment;
15		(D) the health carrier, the covered person, and the
16		covered person's authorized representative shall not
17		choose or control the choice of the physicians or other
18		health care professionals to be selected to conduct the
19		external review;
20		(E) confidentiality of medical and treatment
21		records and clinical review criteria; and
22		(F) any person employed by or under contract with
23		the independent review organization adheres to the
24		requirements of this Act;
25		(2) a toll-free telephone service operating on a
26		24-hour-day, 7-day-a-week basis that accepts, receives,

HB3923 Enrolled - 35 - LRB096 08394 RPM 18506 b
1		and records information related to external reviews and
2		provides appropriate instructions; and
3		(3) an agreement to maintain and provide to the
4		Director the information set out in Section 70 of this Act.
5		(b) All clinical reviewers assigned by an independent
6		review organization to conduct external reviews shall be
7		physicians or other appropriate health care providers who meet
8		the following minimum qualifications:
9		(1) be an expert in the treatment of the covered
10		person's medical condition that is the subject of the
11		external review;
12		(2) be knowledgeable about the recommended health care
13		service or treatment through recent or current actual
14		clinical experience treating patients with the same or
15		similar medical condition of the covered person;
16		(3) hold a non-restricted license in a state of the
17		United States and, for physicians, a current certification
18		by a recognized American medical specialty board in the
19		area or areas appropriate to the subject of the external
20		review; and
21		(4) have no history of disciplinary actions or
22		sanctions, including loss of staff privileges or
23		participation restrictions, that have been taken or are
24		pending by any hospital, governmental agency or unit, or
25		regulatory body that raise a substantial question as to the
26		clinical reviewer's physical, mental, or professional

HB3923 Enrolled - 36 - LRB096 08394 RPM 18506 b
1		competence or moral character.
2		(c) In addition to the requirements set forth in subsection
3		(a), an independent review organization may not own or control,
4		be a subsidiary of, or in any way be owned, or controlled by,
5		or exercise control with a health benefit plan, a national,
6		State, or local trade association of health benefit plans, or a
7		national, State, or local trade association of health care
8		providers.
9		(d) Conflicts of interest prohibited. In addition to the
10		requirements set forth in subsections (a), (b), and (c) of this
11		Section, to be approved pursuant to this Act to conduct an
12		external review of a specified case, neither the independent
13		review organization selected to conduct the external review nor
14		any clinical reviewer assigned by the independent organization
15		to conduct the external review may have a material
16		professional, familial or financial conflict of interest with
17		any of the following:
18		(1) the health carrier that is the subject of the
19		external review;
20		(2) the covered person whose treatment is the subject
21		of the external review or the covered person's authorized
22		representative;
23		(3) any officer, director or management employee of the
24		health carrier that is the subject of the external review;
25		(4) the health care provider, the health care
26		provider's medical group or independent practice

HB3923 Enrolled - 37 - LRB096 08394 RPM 18506 b
1		association recommending the health care service or
2		treatment that is the subject of the external review;
3		(5) the facility at which the recommended health care
4		service or treatment would be provided; or
5		(6) the developer or manufacturer of the principal
6		drug, device, procedure, or other therapy being
7		recommended for the covered person whose treatment is the
8		subject of the external review.
9		(e) An independent review organization that is accredited
10		by a nationally recognized private accrediting entity that has
11		independent review accreditation standards that the Director
12		has determined are equivalent to or exceed the minimum
13		qualifications of this Section shall be presumed to be in
14		compliance with this Section and shall be eligible for approval
15		under this Act.
16		(f) An independent review organization shall be unbiased.
17		An independent review organization shall establish and
18		maintain written procedures to ensure that it is unbiased in
19		addition to any other procedures required under this Section.
20		(g) Nothing in this Act precludes or shall be interpreted
21		to preclude a health carrier from contracting with approved
22		independent review organizations to conduct external reviews
23		assigned to it from such health carrier.
24		Section 60. Hold harmless for independent review
25		organizations. No independent review organization or clinical

HB3923 Enrolled - 38 - LRB096 08394 RPM 18506 b
1		reviewer working on behalf of an independent review
2		organization or an employee, agent or contractor of an
3		independent review organization shall be liable for damages to
4		any person for any opinions rendered or acts or omissions
5		performed within the scope of the organization's or person's
6		duties under the law during or upon completion of an external
7		review conducted pursuant to this Act, unless the opinion was
8		rendered or act or omission performed in bad faith or involved
9		gross negligence.
10		Section 65. External review reporting requirements.
11		(a) Each health carrier shall maintain written records in
12		the aggregate on all requests for external review for each
13		calendar year and submit a report to the Director in the format
14		specified by the Director by March 1 of each year.
15		(b) The report shall include in the aggregate:
16		(1) the total number of requests for external review;
17		(2) the total number of requests for expedited external
18		review;
19		(3) the total number of requests for external review
20		denied;
21		(4) the number of requests for external review
22		resolved, including:
23		(A) the number of requests for external review
24		resolved upholding the adverse determination or final
25		adverse determination;

HB3923 Enrolled - 39 - LRB096 08394 RPM 18506 b
1		(B) the number of requests for external review
2		resolved reversing the adverse determination or final
3		adverse determination;
4		(C) the number of requests for expedited external
5		review resolved upholding the adverse determination or
6		final adverse determination; and
7		(D) the number of requests for expedited external
8		review resolved reversing the adverse determination or
9		final adverse determination;
10		(5) the average length of time for resolution for an
11		external review;
12		(6) the average length of time for resolution for an
13		expedited external review;
14		(7) a summary of the types of coverages or cases for
15		which an external review was sought, as specified below:
16		(A) denial of care or treatment (dissatisfaction
17		regarding prospective non-authorization of a request
18		for care or treatment recommended by a provider
19		excluding diagnostic procedures and referral requests;
20		partial approvals and care terminations are also
21		considered to be denials);
22		(B) denial of diagnostic procedure
23		(dissatisfaction regarding prospective
24		non-authorization of a request for a diagnostic
25		procedure recommended by a provider; partial approvals
26		are also considered to be denials);

HB3923 Enrolled - 40 - LRB096 08394 RPM 18506 b
1		(C) denial of referral request (dissatisfaction
2		regarding non-authorization of a request for a
3		referral to another provider recommended by a PCP);
4		(D) claims and utilization review (dissatisfaction
5		regarding the concurrent or retrospective evaluation
6		of the coverage, medical necessity, efficiency or
7		appropriateness of health care services or treatment
8		plans; prospective "Denials of care or treatment",
9		"Denials of diagnostic procedures" and "Denials of
10		referral requests" should not be classified in this
11		category, but the appropriate one above);
12		(8) the number of external reviews that were terminated
13		as the result of a reconsideration by the health carrier of
14		its adverse determination or final adverse determination
15		after the receipt of additional information from the
16		covered person or the covered person's authorized
17		representative; and
18		(9) any other information the Director may request or
19		require.
20		Section 70. Funding of external review. The health carrier
21		shall be solely responsible for paying the cost of external
22		reviews conducted by independent review organizations.
23		Section 75. Disclosure requirements.
24		(a) Each health carrier shall include a description of the

HB3923 Enrolled - 41 - LRB096 08394 RPM 18506 b
1		external review procedures in, or attached to, the policy,
2		certificate, membership booklet, and outline of coverage or
3		other evidence of coverage it provides to covered persons.
4		(b) The description required under subsection (a) of this
5		Section shall include a statement that informs the covered
6		person of the right of the covered person to file a request for
7		an external review of an adverse determination or final adverse
8		determination with the health carrier. The statement shall
9		explain that external review is available when the adverse
10		determination or final adverse determination involves an issue
11		of medical necessity, appropriateness, health care setting,
12		level of care, or effectiveness. The statement shall include
13		the toll-free telephone number and address of the Office of
14		Consumer Health Insurance within the Department of Insurance.
15		Section 90. The Illinois Insurance Code is amended by
16		changing Section 155.36 and by adding Sections 359b and 359c as
17		follows:
18		(215 ILCS 5/155.36)
19		Sec. 155.36. Managed Care Reform and Patient Rights Act.
20		Insurance companies that transact the kinds of insurance
21		authorized under Class 1(b) or Class 2(a) of Section 4 of this
22		Code shall comply with Sections 45 and Section 85 and the
23		definition of the term "emergency medical condition" in Section
24		10 of the Managed Care Reform and Patient Rights Act.

HB3923 Enrolled - 42 - LRB096 08394 RPM 18506 b
1		(Source: P.A. 91-617, eff. 1-1-00.)
2		(215 ILCS 5/359b new)
3		Sec. 359b. Committee to create a uniform small employer
4		group-health status questionnaire and individual health
5		statement.
6		(a) For the purposes of this Section:
7		"Employee health-status questionnaire" means a
8		questionnaire that poses questions about an individual
9		employee's or covered dependent's health history and that is to
10		be completed by the individual employee or covered dependent of
11		a small employer that seeks health insurance coverage from a
12		small employer carrier.
13		"Health benefit plan", "small employer", and "small
14		employer carrier" shall have the meaning given the terms in the
15		Small Employer Health Insurance Rating Act.
16		"Individual health insurance coverage" and "individual
17		market" shall have the meaning given the terms in the Illinois
18		Health Insurance Portability and Accountability Act.
19		(b) A committee is established in the Department consisting
20		of 11 members, including the Director or the Director's
21		designee, who are appointed by the Director. The Director shall
22		appoint to the committee 5 representatives as recommended by
23		the Illinois Insurance Association, Illinois Life Insurance
24		Council, Professional Independent Insurance Agents of
25		Illinois, Illinois Association of Health Underwriters,

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

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1		shall be mandatory.
2		(d) On or before July 1, 2010, the committee shall develop
3		the uniform employee health-status questionnaire for adoption
4		by the Department. Beginning January 1, 2011, a small employer
5		carrier shall use the questionnaire for all small employer
6		groups for which it requires employees and their covered
7		dependents to complete questionnaires.
8		(e) The Director, as needed, may reconvene the committee to
9		consider whether changes are necessary to the uniform employee
10		health status questionnaire. If the committee determines that
11		changes to the questionnaire are necessary, then the Director
12		may adopt revisions to the questionnaire as recommended by the
13		committee. Small employer carriers shall use the revised
14		questionnaire beginning 90 days after the Director adopts any
15		revision.
16		(f) Nothing in this Section shall be construed to limit or
17		restrict a small employer carrier's ability to appropriately
18		rate risk under a small employer health benefit plan.
19		(g) On or before July 1, 2010, the committee shall develop
20		a standard individual market health statement to simplify the
21		health insurance application process for individuals. The
22		committee shall study health statements currently used by major
23		carriers in this State who offer individual health insurance
24		coverage and consolidate the statements into a standard
25		individual market health statement. The standard individual
26		market health statement shall be designed to permit its use

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1		both as a written document and through electronic or other
2		alternative delivery formats. For purposes of the individual
3		market health statement, the Director may, but shall not be
4		required to, establish a committee distinct from that formed to
5		develop an application for small employers. In that event, the
6		composition of the committee shall be as prescribed in
7		subsection (b) of this Section, although individual
8		participants may change.
9		(h) Beginning January 1, 2011, all carriers who offer
10		individual health insurance coverage and evaluate the health
11		status of individuals shall use the standard individual market
12		health statement.
13		(i) The Director, as needed, may reconvene the committee to
14		consider whether changes are necessary to the standard
15		individual market health statement. If the committee
16		determines that changes to the statement are necessary, the
17		Director may adopt revisions to the statement as recommended by
18		the committee. All carriers who offer individual health
19		insurance coverage shall use the revised statement beginning 90
20		days after the Director adopts any revision.
21		(j) Nothing in this Section shall prevent a carrier from
22		using health information after enrollment for the purpose of
23		providing services or arranging for the provision of services
24		under a health benefit plan or a policy of individual health
25		insurance coverage.
26		(k) Nothing in this Section shall be construed to limit or

HB3923 Enrolled - 46 - LRB096 08394 RPM 18506 b
1		restrict a health carrier's ability to appropriately rate risk,
2		refuse to issue or renew coverage, or otherwise rescind,
3		terminate, or restrict coverage under a health benefit plan or
4		a policy of individual health insurance coverage or conduct
5		further review of the information submitted on the statement by
6		contacting an individual, the individual's health care
7		provider, or any other entity for additional health status
8		related information.
9		(l) Committee members are not eligible for compensation but
10		may receive reimbursement of expenses.
11		(215 ILCS 5/359c new)
12		Sec. 359c. Accident and health expense reporting.
13		(a) Beginning January 1, 2011 and every 6 months
14		thereafter, any carrier providing a group or individual major
15		medical policy of accident or health insurance shall prepare
16		and provide to the Department of Insurance a statement of the
17		aggregate administrative expenses of the carrier, based on the
18		premiums earned in the immediately preceding 6-month period on
19		the accident or health insurance business of the carrier. The
20		semi-annual statements shall be filed on or before July 31 for
21		the preceding 6-month period ending June 30 and on or before
22		February 1 for the preceding 6-month period ending December 31.
23		The statements shall itemize and separately detail all of the
24		following information with respect to the carrier's accident or
25		health insurance business:

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1		(1) the amount of premiums earned by the carrier both
2		before and after any costs related to the carrier's
3		purchase of reinsurance coverage;
4		(2) the total amount of claims for losses paid by the
5		carrier both before and after any reimbursement from
6		reinsurance coverage including any costs incurred related
7		to:
8		(A) disease, case, or chronic care management
9		programs;
10		(B) wellness and health education programs;
11		(C) fraud prevention;
12		(D) maintaining provider networks and provider
13		credentialing;
14		(E) health information technology for personal
15		electronic health records; and
16		(F) utilization review and utilization management;
17		(3) the amount of any losses incurred by the carrier
18		but not reported to the carrier in the current or prior
19		reporting period;
20		(4) the amount of costs incurred by the carrier for
21		State fees and federal and State taxes including:
22		(A) any high risk pool and guaranty fund
23		assessments levied on the carrier by the State; and
24		(B) any regulatory compliance costs including
25		State fees for form and rate filings, licensures,
26		market conduct exams, and financial reports;

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1		(5) the amount of costs incurred by the carrier for
2		reinsurance coverage;
3		(6) the amount of costs incurred by the carrier that
4		are related to the carrier's payment of marketing expenses
5		including commissions; and
6		(7) any other administrative expenses incurred by the
7		carrier.
8		(b) The information provided pursuant to subsection (a) of
9		this Section shall be separately aggregated for the following
10		lines of major medical insurance:
11		(1) individually underwritten;
12		(2) groups of 2 to 25 members;
13		(3) groups of 26 to 50 members;
14		(4) groups of 51 or more members.
15		(c) The Department shall make the submitted information
16		publicly available on the Department's website or such other
17		media as appropriate in a form useful for consumers.
18		Section 95. The Managed Care Reform and Patient Rights Act
19		is amended by changing Sections 40 and 45 as follows:
20		(215 ILCS 134/40)
21		Sec. 40. Access to specialists.
22		(a) All health care plans that require each enrollee to
23		select a health care provider for any purpose including
24		coordination of care shall permit an enrollee to choose any

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

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1		physician or to select a new primary care physician who has a
2		referral arrangement with the specialist physician or other
3		health care provider chosen by the enrollee. If a health care
4		plan requires an enrollee to select a new physician under this
5		subsection, the health care plan must provide the enrollee with
6		both options provided in this subsection. When a participating
7		specialist with a referral arrangement is not available, the
8		primary care physician, in consultation with the enrollee,
9		shall arrange for the enrollee to have access to a qualified
10		participating health care provider, and the enrollee shall be
11		allowed to stay with his or her primary care physician. If a
12		secondary referral is necessary, the specialist physician or
13		other health care provider shall advise the primary care
14		physician. The primary care physician shall be responsible for
15		making the secondary referral. In addition, the health care
16		plan shall require the specialist physician or other health
17		care provider to provide regular updates to the enrollee's
18		primary care physician.
19		(d) When the type of specialist physician or other health
20		care provider needed to provide ongoing care for a specific
21		condition is not represented in the health care plan's provider
22		network, the primary care physician shall arrange for the
23		enrollee to have access to a qualified non-participating health
24		care provider within a reasonable distance and travel time at
25		no additional cost beyond what the enrollee would otherwise pay
26		for services received within the network. The referring

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

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1		(Source: P.A. 91-617, eff. 1-1-00.)
2		(215 ILCS 134/45)
3		Sec. 45. Health care services appeals, complaints, and
4		external independent reviews.
5		(a) A health care plan shall establish and maintain an
6		appeals procedure as outlined in this Act. Compliance with this
7		Act's appeals procedures shall satisfy a health care plan's
8		obligation to provide appeal procedures under any other State
9		law or rules. All appeals of a health care plan's
10		administrative determinations and complaints regarding its
11		administrative decisions shall be handled as required under
12		Section 50.
13		(b) When an appeal concerns a decision or action by a
14		health care plan, its employees, or its subcontractors that
15		relates to (i) health care services, including, but not limited
16		to, procedures or treatments, for an enrollee with an ongoing
17		course of treatment ordered by a health care provider, the
18		denial of which could significantly increase the risk to an
19		enrollee's health, or (ii) a treatment referral, service,
20		procedure, or other health care service, the denial of which
21		could significantly increase the risk to an enrollee's health,
22		the health care plan must allow for the filing of an appeal
23		either orally or in writing. Upon submission of the appeal, a
24		health care plan must notify the party filing the appeal, as
25		soon as possible, but in no event more than 24 hours after the

HB3923 Enrolled - 53 - LRB096 08394 RPM 18506 b
1		submission of the appeal, of all information that the plan
2		requires to evaluate the appeal. The health care plan shall
3		render a decision on the appeal within 24 hours after receipt
4		of the required information. The health care plan shall notify
5		the party filing the appeal and the enrollee, enrollee's
6		primary care physician, and any health care provider who
7		recommended the health care service involved in the appeal of
8		its decision orally followed-up by a written notice of the
9		determination.
10		(c) For all appeals related to health care services
11		including, but not limited to, procedures or treatments for an
12		enrollee and not covered by subsection (b) above, the health
13		care plan shall establish a procedure for the filing of such
14		appeals. Upon submission of an appeal under this subsection, a
15		health care plan must notify the party filing an appeal, within
16		3 business days, of all information that the plan requires to
17		evaluate the appeal. The health care plan shall render a
18		decision on the appeal within 15 business days after receipt of
19		the required information. The health care plan shall notify the
20		party filing the appeal, the enrollee, the enrollee's primary
21		care physician, and any health care provider who recommended
22		the health care service involved in the appeal orally of its
23		decision followed-up by a written notice of the determination.
24		(d) An appeal under subsection (b) or (c) may be filed by
25		the enrollee, the enrollee's designee or guardian, the
26		enrollee's primary care physician, or the enrollee's health

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

HB3923 Enrolled - 55 - LRB096 08394 RPM 18506 b
1		person, the covered person has the right to appeal the final
2		decision to the Department; if the external review decision is
3		found by the Director to have been arbitrary and capricious,
4		then the Director, with consultation from a licensed medical
5		professional, may overturn the external review decision and
6		require the health carrier to pay for the health care service
7		or treatment; such decision, if any, shall be made solely on
8		the legal or medical merits of the claim. If an external review
9		decision is overturned by the Director pursuant to this Section
10		and the health carrier so requests, then the Director shall
11		assign a new independent review organization to reconsider the
12		overturned decision. The new independent review organization
13		shall follow subsection (d) of Section 40 of the Health Carrier
14		External Review Act in rendering a decision. External
15		independent review.
16		(1) The party seeking an external independent review
17		shall so notify the health care plan. The health care plan
18		shall seek to resolve all external independent reviews in
19		the most expeditious manner and shall make a determination
20		and provide notice of the determination no more than 24
21		hours after the receipt of all necessary information when a
22		delay would significantly increase the risk to an
23		enrollee's health or when extended health care services for
24		an enrollee undergoing a course of treatment prescribed by
25		a health care provider are at issue.
26		(2) Within 30 days after the enrollee receives written

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

HB3923 Enrolled - 57 - LRB096 08394 RPM 18506 b
1		be medically appropriate, the health care plan shall pay
2		for the health care service.
3		(5) The health care plan shall be solely responsible
4		for paying the fees of the external independent reviewer
5		who is selected to perform the review.
6		(6) An external independent reviewer who acts in good
7		faith shall have immunity from any civil or criminal
8		liability or professional discipline as a result of acts or
9		omissions with respect to any external independent review,
10		unless the acts or omissions constitute wilful and wanton
11		misconduct. For purposes of any proceeding, the good faith
12		of the person participating shall be presumed.
13		(g) (7) Future contractual or employment action by the
14		health care plan regarding the patient's physician or other
15		health care provider shall not be based solely on the
16		physician's or other health care provider's participation
17		in health care services appeals, complaints, or external
18		independent reviews under the Illinois Health Carrier
19		External Review Act this procedure.
20		(8) For the purposes of this Section, an external
21		independent reviewer shall:
22		(A) be a clinical peer;
23		(B) have no direct financial interest in
24		connection with the case; and
25		(C) have not been informed of the specific identity
26		of the enrollee.

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1		(h) (g) Nothing in this Section shall be construed to
2		require a health care plan to pay for a health care service not
3		covered under the enrollee's certificate of coverage or policy.
4		(Source: P.A. 91-617, eff. 1-1-00.)
5		Section 96. No acceleration or delay. Where this Act makes
6		changes in a statute that is represented in this Act by text
7		that is not yet or no longer in effect (for example, a Section
8		represented by multiple versions), the use of that text does
9		not accelerate or delay the taking effect of (i) the changes
10		made by this Act or (ii) provisions derived from any other
11		Public Act.
12		Section 97. Severability. The provisions of this Act are
13		severable under Section 1.31 of the Statute on Statutes.
14		Section 99. Effective date. This Act takes effect January
15		1, 2010, except that the changes to Section 155.36 of the
16		Illinois Insurance Code and Sections 40 and 45 of the Managed
17		Care Reform and Patient Rights Act and the Health Carrier
18