    Section 30. The Managed Care Reform and Patient Rights Act
is amended by changing Sections 10, 45, and 85 as follows:
 
    (215 ILCS 134/10)
    Sec. 10. Definitions. In this Act:
    For a health care plan under Section 45 or for a
utilization review program under Section 85, "adverse
determination" has the meaning given to that term in Section
10 of the Health Carrier External Review Act.
    "Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
    "Department" means the Department of Insurance.
    "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
regardless of the final diagnosis given, such that a prudent
layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in:
        (1) placing the health of the individual (or, with
    respect to a pregnant woman, the health of the woman or her
    unborn child) in serious jeopardy;
        (2) serious impairment to bodily functions;
        (3) serious dysfunction of any bodily organ or part;
        (4) inadequately controlled pain; or
        (5) with respect to a pregnant woman who is having
    contractions:
            (A) inadequate time to complete a safe transfer to
        another hospital before delivery; or
            (B) a transfer to another hospital may pose a
        threat to the health or safety of the woman or unborn
        child.
    "Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
    "Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
    "Enrollee" means any person and his or her dependents
enrolled in or covered by a health care plan.
    "Health care plan" means a plan, including, but not
limited to, a health maintenance organization, a managed care
community network as defined in the Illinois Public Aid Code,
or an accountable care entity as defined in the Illinois
Public Aid Code that receives capitated payments to cover
medical services from the Department of Healthcare and Family
Services, that establishes, operates, or maintains a network
of health care providers that has entered into an agreement
with the plan to provide health care services to enrollees to
whom the plan has the ultimate obligation to arrange for the
provision of or payment for services through organizational
arrangements for ongoing quality assurance, utilization review
programs, or dispute resolution. Nothing in this definition
shall be construed to mean that an independent practice
association or a physician hospital organization that
subcontracts with a health care plan is, for purposes of that
subcontract, a health care plan.
    For purposes of this definition, "health care plan" shall
not include the following:
        (1) indemnity health insurance policies including
    those using a contracted provider network;
        (2) health care plans that offer only dental or only
    vision coverage;
        (3) preferred provider administrators, as defined in
    Section 370g(g) of the Illinois Insurance Code;
        (4) employee or employer self-insured health benefit
    plans under the federal Employee Retirement Income
    Security Act of 1974;
        (5) health care provided pursuant to the Workers'
    Compensation Act or the Workers' Occupational Diseases
    Act; and
        (6) except with respect to subsections (a) and (b) of
    Section 65 and subsection (a-5) of Section 70,
    not-for-profit voluntary health services plans with health
    maintenance organization authority in existence as of
    January 1, 1999 that are affiliated with a union and that
    only extend coverage to union members and their
    dependents.
    "Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.
    "Health care provider" means any physician, hospital
facility, facility licensed under the Nursing Home Care Act,
long-term care facility as defined in Section 1-113 of the
Nursing Home Care Act, or other person that is licensed or
otherwise authorized to deliver health care services. Nothing
in this Act shall be construed to define Independent Practice
Associations or Physician-Hospital Organizations as health
care providers.
    "Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all other
services for the purpose of preventing, alleviating, curing,
or healing human illness or injury including behavioral
health, mental health, home health, and pharmaceutical
services and products.
    "Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health
care plan.
    "Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
    "Physician" means a person licensed under the Medical
Practice Act of 1987.
    "Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
    "Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
    "Utilization review" means the evaluation, including any
evaluation based on an algorithmic automated process, of the
medical necessity, appropriateness, and efficiency of the use
of health care services, procedures, and facilities.
    "Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
    (215 ILCS 134/45)
    Sec. 45. Health care services appeals, complaints, and
external independent reviews.
    (a) A health care plan shall establish and maintain an
appeals procedure as outlined in this Act. Compliance with
this Act's appeals procedures shall satisfy a health care
plan's obligation to provide appeal procedures under any other
State law or rules. All appeals of a health care plan's
administrative determinations and complaints regarding its
administrative decisions shall be handled as required under
Section 50.
    (b) When an appeal concerns a decision or action by a
health care plan, its employees, or its subcontractors that
relates to (i) health care services, including, but not
limited to, procedures or treatments, for an enrollee with an
ongoing course of treatment ordered by a health care provider,
the denial of which could significantly increase the risk to
an enrollee's health, or (ii) a treatment referral, service,
procedure, or other health care service, the denial of which
could significantly increase the risk to an enrollee's health,
the health care plan must allow for the filing of an appeal
either orally or in writing. Upon submission of the appeal, a
health care plan must notify the party filing the appeal, as
soon as possible, but in no event more than 24 hours after the
submission of the appeal, of all information that the plan
requires to evaluate the appeal. The health care plan shall
render a decision on the appeal within 24 hours after receipt
of the required information. The health care plan shall notify
the party filing the appeal and the enrollee, enrollee's
primary care physician, and any health care provider who
recommended the health care service involved in the appeal of
its decision orally followed-up by a written notice of the
determination.
    (c) For all appeals related to health care services
including, but not limited to, procedures or treatments for an
enrollee and not covered by subsection (b) above, the health
care plan shall establish a procedure for the filing of such
appeals. Upon submission of an appeal under this subsection, a
health care plan must notify the party filing an appeal,
within 3 business days, of all information that the plan
requires to evaluate the appeal. The health care plan shall
render a decision on the appeal within 15 business days after
receipt of the required information. The health care plan
shall notify the party filing the appeal, the enrollee, the
enrollee's primary care physician, and any health care
provider who recommended the health care service involved in
the appeal orally of its decision followed-up by a written
notice of the determination.
    (d) An appeal under subsection (b) or (c) may be filed by
the enrollee, the enrollee's designee or guardian, the
enrollee's primary care physician, or the enrollee's health
care provider. A health care plan shall designate a clinical
peer to review appeals, because these appeals pertain to
medical or clinical matters and such an appeal must be
reviewed by an appropriate health care professional. No one
reviewing an appeal may have had any involvement in the
initial determination that is the subject of the appeal. The
written notice of determination required under subsections (b)
and (c) shall include (i) clear and detailed reasons for the
determination, (ii) the medical or clinical criteria for the
determination, which shall be based upon sound clinical
evidence and reviewed on a periodic basis, and (iii) in the
case of an adverse determination, the procedures for
requesting an external independent review as provided by the
Illinois Health Carrier External Review Act.
    (e) If an appeal filed under subsection (b) or (c) is
denied for a reason including, but not limited to, the
service, procedure, or treatment is not viewed as medically
necessary, denial of specific tests or procedures, denial of
referral to specialist physicians or denial of hospitalization
requests or length of stay requests, any involved party may
request an external independent review as provided by the
Illinois Health Carrier External Review Act.
    (f) Until July 1, 2013, if an external independent review
decision made pursuant to the Illinois Health Carrier External
Review Act upholds a determination adverse to the covered
person, the covered person has the right to appeal the final
decision to the Department; if the external review decision is
found by the Director to have been arbitrary and capricious,
then the Director, with consultation from a licensed medical
professional, may overturn the external review decision and
require the health carrier to pay for the health care service
or treatment; such decision, if any, shall be made solely on
the legal or medical merits of the claim. If an external review
decision is overturned by the Director pursuant to this
Section and the health carrier so requests, then the Director
shall assign a new independent review organization to
reconsider the overturned decision. The new independent review
organization shall follow subsection (d) of Section 40 of the
Health Carrier External Review Act in rendering a decision.
    (g) Future contractual or employment action by the health
care plan regarding the patient's physician or other health
care provider shall not be based solely on the physician's or
other health care provider's participation in health care
services appeals, complaints, or external independent reviews
under the Illinois Health Carrier External Review Act.
    (h) Nothing in this Section shall be construed to require
a health care plan to pay for a health care service not covered
under the enrollee's certificate of coverage or policy.
    (i) Even if a health care plan or other utilization review
program uses an algorithmic automated process in the course of
utilization review for medical necessity, the health care plan
or other utilization review program shall ensure that only a
clinical peer makes any adverse determination based on medical
necessity and that any subsequent appeal is processed as
required by this Section, including the restriction that only
a clinical peer may review an appeal. A health care plan or
other utilization review program using an automated process
shall have the accreditation and the policies and procedures
required by subsection (b-10) of Section 85 of this Act.
(Source: P.A. 96-857, eff. 7-1-10.)
 
    (215 ILCS 134/85)
    Sec. 85. Utilization review program registration.
    (a) No person may conduct a utilization review program in
this State unless once every 2 years the person registers the
utilization review program with the Department and provides
proof of current accreditation for itself and its
subcontractors with the Health
Utilization Management Standards of the Utilization Review
Accreditation Commission, the National Committee for Quality
Assurance, or another accreditation entity authorized under
this Section.
    (b) In addition, the Director of the Department, in
consultation with the Director of the Department of Public
Health, may certify alternative utilization review standards
of national accreditation organizations or entities in order
for plans to comply with this Section. Any alternative
utilization review standards shall meet or exceed those
standards required under subsection (a).
    (b-5) The Department shall recognize the Accreditation
Association for Ambulatory Health Care among the list of
accreditors from which utilization organizations may receive
accreditation and qualify for reduced registration and renewal
fees.
    (b-10) Utilization review programs that use algorithmic
automated processes to decide whether to render adverse
determinations based on medical necessity in the course of
utilization review shall use objective, evidence-based
criteria compliant with the accreditation requirements of the
Health Utilization Management Standards of the Utilization
Review Accreditation Commission or the National Committee for
Quality Assurance (NCQA) and shall provide proof of such
compliance to the Department with the registration required
under subsection (a), including any renewal registrations.
Nothing in this subsection supersedes paragraph (2) of
subsection (e). The utilization review program shall include,
with its registration materials, attachments that contain
policies and procedures:
        (1) to ensure that licensed physicians with relevant
    board certifications establish all criteria that the
    algorithmic automated process uses for utilization review;
    and
        (2) for a program integrity system that, both before
    new or revised criteria are used for utilization review
    and when implementation errors in the algorithmic
    automated process are identified after new or revised
    criteria go into effect, requires licensed physicians with
    relevant board certifications to verify that the
    algorithmic automated process and corrections to it yield
    results consistent with the criteria for their certified
    field.
    (c) The provisions of this Section do not apply to:
        (1) persons providing utilization review program
    services only to the federal government;
        (2) self-insured health plans under the federal
    Employee Retirement Income Security Act of 1974, however,
    this Section does apply to persons conducting a
    utilization review program on behalf of these health
    plans;
        (3) hospitals and medical groups performing
    utilization review activities for internal purposes unless
    the utilization review program is conducted for another
    person.
    Nothing in this Act prohibits a health care plan or other
entity from contractually requiring an entity designated in
item (3) of this subsection to adhere to the utilization
review program requirements of this Act.
    (d) This registration shall include submission of all of
the following information regarding utilization review program
activities:
        (1) The name, address, and telephone number of the
    utilization review programs.
        (2) The organization and governing structure of the
    utilization review programs.
        (3) The number of lives for which utilization review
    is conducted by each utilization review program.
        (4) Hours of operation of each utilization review
    program.
        (5) Description of the grievance process for each
    utilization review program.
        (6) Number of covered lives for which utilization
    review was conducted for the previous calendar year for
    each utilization review program.
        (7) Written policies and procedures for protecting
    confidential information according to applicable State and
    federal laws for each utilization review program.
    (e) (1) A utilization review program shall have written
procedures for assuring that patient-specific information
obtained during the process of utilization review will be:
        (A) kept confidential in accordance with applicable
    State and federal laws; and
        (B) shared only with the enrollee, the enrollee's
    designee, the enrollee's health care provider, and those
    who are authorized by law to receive the information.
    Summary data shall not be considered confidential if it
does not provide information to allow identification of
individual patients or health care providers.
        (2) Only a clinical peer may
    make adverse determinations regarding the medical
    necessity of health care services during the course of
    utilization review. Either a health care professional or
    an accredited algorithmic automated process, or both in
    combination, may certify the medical necessity of a health
    care service in accordance with accreditation standards.
    Nothing in this subsection prohibits an accredited
    algorithmic automated process from being used to refer a
    case to a clinical peer for a potential adverse
    determination.
        (3) When making retrospective reviews, utilization
    review programs shall base reviews solely on the medical
    information available to the attending physician or
    ordering provider at the time the health care services
    were provided. This paragraph includes billing records and
    diagnosis or procedure codes that substantively contain
    the same medical information to an equal or lesser degree
    of specificity as the records the attending physician or
    ordering provider directly consulted at the time health
    care services were provided.
        (4) When making prospective, concurrent, and
    retrospective determinations, utilization review programs
    shall collect only information that is necessary to make
    the determination and shall not routinely require health
    care providers to numerically code diagnoses or procedures
    to be considered for certification, unless required under
    State or federal Medicare or Medicaid rules or
    regulations, but may request such code if available, or
    routinely request copies of medical records of all
    enrollees reviewed. During prospective or concurrent
    review, copies of medical records shall only be required
    when necessary to verify that the health care services
    subject to review are medically necessary. In these cases,
    only the necessary or relevant sections of the medical
    record shall be required.
    (f) If the Department finds that a utilization review
program is not in compliance with this Section, the Department
shall issue a corrective action plan and allow a reasonable
amount of time for compliance with the plan. If the
utilization review program does not come into compliance, the
Department may issue a cease and desist order. Before issuing
a cease and desist order under this Section, the Department
shall provide the utilization review program with a written
notice of the reasons for the order and allow a reasonable
amount of time to supply additional information demonstrating
compliance with requirements of this Section and to request a
hearing. The hearing notice shall be sent by certified mail,
return receipt requested, and the hearing shall be conducted
in accordance with the Illinois Administrative Procedure Act.
    (g) A utilization review program subject to a corrective
action may continue to conduct business until a final decision
has been issued by the Department.
    (h) Any adverse determination made by a health care plan
or its subcontractors may be appealed in accordance with
subsection (f) of Section 45.
    (i) The Director may by rule establish a registration fee
for each person conducting a utilization review program. All
fees paid to and collected by the Director under this Section
shall be deposited into the Insurance Producer Administration
Fund.
(Source: P.A. 99-111, eff. 1-1-16.)