Bill Text: IL HB5079 | 2009-2010 | 96th General Assembly | Engrossed

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

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Bill Title: Amends the Health Carrier External Review Act. In the provision concerning standard external review, provides that before a determination on an appeal relating to a determination based on treatment being experimental or investigational is made, a physician licensed under the Medical Practice Act of 1987 (instead of licensed to practice medicine in all its branches) shall certify that a certain situation is applicable. Contains a nonacceleration clause.

Sponsorship: Partisan Bill (Democrat 1)

Status: (Passed) 2010-07-02 - Public Act . . . . . . . . . 96-0967 [HB5079 Detail]

Download: Illinois-2009-HB5079-Engrossed.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 5. The Health Carrier External Review Act is
amended by changing Section 35 as follows:
(215 ILCS 180/35)
(This Section may contain text from a Public Act with a
delayed effective date)
Sec. 35. Standard external review.
(a) Within 4 months after the date of receipt of a notice
of an adverse determination or final adverse determination, a
covered person or the covered person's authorized
representative may file a request for an external review with
the health carrier.
(b) Within 5 business days following the date of receipt of
the external review request, the health carrier shall complete
a preliminary review of the request to determine whether:
(1) the individual is or was a covered person in the
health benefit plan at the time the health care service was
requested or at the time the health care service was
provided;
(2) the health care service that is the subject of the
adverse determination or the final adverse determination

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is a covered service under the covered person's health
benefit plan, but the health carrier has determined that
the health care service is not covered because it does not
meet the health carrier's requirements for medical
necessity, appropriateness, health care setting, level of
care, or effectiveness;
(3) the covered person has exhausted the health
carrier's internal grievance process as set forth in this
Act;
(4) for appeals relating to a determination based on
treatment being experimental or investigational, the
requested health care service or treatment that is the
subject of the adverse determination or final adverse
determination is a covered benefit under the covered
person's health benefit plan except for the health
carrier's determination that the service or treatment is
experimental or investigational for a particular medical
condition and is not explicitly listed as an excluded
benefit under the covered person's health benefit plan with
the health carrier and that the covered person's health
care provider, who ordered or provided the services in
question and who is licensed under the Medical Practice Act
of 1987 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

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have not been effective in improving the condition of
the covered person;
(B) standard health care services or treatments
are not medically appropriate for the covered person;
(C) there is no available standard health care
service or treatment covered by the health carrier that
is more beneficial than the recommended or requested
health care service or treatment;
(D) the health care service or treatment is likely
to be more beneficial to the covered person, in the
health care provider's opinion, than any available
standard health care services or treatments; or
(E) that scientifically valid studies using
accepted protocols demonstrate that the health care
service or treatment requested is likely to be more
beneficial to the covered person than any available
standard health care services or treatments; and
(5) the covered person has provided all the information
and forms required to process an external review, as
specified in this Act.
(c) Within one business day after completion of the
preliminary review, the health carrier shall notify the covered
person and, if applicable, the covered person's authorized
representative in writing whether the request is complete and
eligible for external review. If the request:
(1) is not complete, the health carrier shall inform

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the covered person and, if applicable, the covered person's
authorized representative in writing and include in the
notice what information or materials are required by this
Act to make the request complete; or
(2) is not eligible for external review, the health
carrier shall inform the covered person and, if applicable,
the covered person's authorized representative in writing
and include in the notice the reasons for its
ineligibility.
The notice of initial determination of ineligibility shall
include a statement informing the covered person and, if
applicable, the covered person's authorized representative
that a health carrier's initial determination that the external
review request is ineligible for review may be appealed to the
Director by filing a complaint with the Director.
Notwithstanding a health carrier's initial determination
that the request is ineligible for external review, the
Director may determine that a request is eligible for external
review and require that it be referred for external review. In
making such determination, the Director's decision shall be in
accordance with the terms of the covered person's health
benefit plan and shall be subject to all applicable provisions
of this Act.
(d) Whenever a request is eligible for external review the
health carrier shall, within 5 business days:
(1) assign an independent review organization from the

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list of approved independent review organizations compiled
and maintained by the Director; and
(2) notify in writing the covered person and, if
applicable, the covered person's authorized representative
of the request's eligibility and acceptance for external
review and the name of the independent review organization.
The health carrier shall include in the notice provided to
the covered person and, if applicable, the covered person's
authorized representative a statement that the covered person
or the covered person's authorized representative may, within 5
business days following the date of receipt of the notice
provided pursuant to item (2) of this subsection (d), submit in
writing to the assigned independent review organization
additional information that the independent review
organization shall consider when conducting the external
review. The independent review organization is not required to,
but may, accept and consider additional information submitted
after 5 business days.
(e) The assignment of an approved independent review
organization to conduct an external review in accordance with
this Section shall be made from those approved independent
review organizations qualified to conduct external review as
required by Sections 50 and 55 of this Act.
(f) Upon assignment of an independent review organization,
the health carrier or its designee utilization review
organization shall, within 5 business days, provide to the

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

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information and documents and any other information submitted
in writing to the independent review organization by the
covered person and the covered person's authorized
representative.
(h) Upon receipt of any information submitted by the
covered person or the covered person's authorized
representative, the independent review organization shall
forward the information to the health carrier within 1 business
day.
(1) Upon receipt of the information, if any, the health
carrier may reconsider its adverse determination or final
adverse determination that is the subject of the external
review.
(2) Reconsideration by the health carrier of its
adverse determination or final adverse determination shall
not delay or terminate the external review.
(3) The external review may only be terminated if the
health carrier decides, upon completion of its
reconsideration, to reverse its adverse determination or
final adverse determination and provide coverage or
payment for the health care service that is the subject of
the adverse determination or final adverse determination.
In such cases, the following provisions shall apply:
(A) Within one business day after making the
decision to reverse its adverse determination or final
adverse determination, the health carrier shall notify

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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
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

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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:
(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;

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(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
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

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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:
(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

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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
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

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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.
(Source: P.A. 96-857, eff. 7-1-10.)
Section 95. 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.