215 ILCS 200/1
Short title
Short title. This Act may be cited as the Prior Authorization Reform Act. (Source: P.A. 102-409, eff. 1-1-22.)
Illinois Compiled Statutes 215 ILCS 200 — Prior Authorization Reform Act.
Illinois · statute · 215 ILCS 200 · 23 active provisions
215 ILCS 200/5
Purpose
Purpose. The General Assembly hereby finds and declares that: (1) the health care professional-patient relationship is paramount and should not be subject to third-party intrusion; (2) prior authorization programs shall be subject to member coverage agreements and medical policies but shall not hinder the independent m…
215 ILCS 200/10
Applicability; scope
Applicability; scope. This Act applies to health insurance coverage as defined in the Illinois Health Insurance Portability and Accountability Act, and policies issued or delivered in this State to the Department of Healthcare and Family Services and providing coverage to persons who are enrolled under Article V of the…
215 ILCS 200/15
Definitions
Definitions. As used in this Act: "Adverse determination" has the meaning given to that term in Section 10 of the Health Carrier External Review Act. "Appeal" means a formal request, either orally or in writing, to reconsider an adverse determination. "Approval" means a determination by a health insurance issuer or its…
215 ILCS 200/20
Disclosure and review of prior authorization requirements
Disclosure and review of prior authorization requirements. (a) A health insurance issuer shall maintain a complete list of services for which prior authorization is required, including for all services where prior authorization is performed by an entity under contract with the health insurance issuer. The health insura…
215 ILCS 200/25
Health insurance issuer's and its contracted utilization review organization's obligations with respect to prior authorizations in nonurgent circumstances
Health insurance issuer's and its contracted utilization review organization's obligations with respect to prior authorizations in nonurgent circumstances. Notwithstanding any other provision of law, if a health insurance issuer requires prior authorization of a health care service, the health insurance issuer or its c…
215 ILCS 200/30
Health insurance issuer's and its contracted utilization review organization's obligations with respect to prior authorizations concerning urgent health care services
Health insurance issuer's and its contracted utilization review organization's obligations with respect to prior authorizations concerning urgent health care services. (a) Notwithstanding any other provision of law, a health insurance issuer or its contracted utilization review organization must render an approval or a…
215 ILCS 200/35
Personnel qualified to make adverse determinations of a prior authorization request
Personnel qualified to make adverse determinations of a prior authorization request. A health insurance issuer or its contracted utilization review organization must ensure that all adverse determinations are made by a physician when the request is by a physician or a representative of a physician. The physician must:…
215 ILCS 200/40
Requirements for adverse determination
Requirements for adverse determination. If a health insurance issuer or its contracted utilization review organization makes an adverse determination, the health insurance issuer or its contracted utilization review organization shall include the following in the notification to the enrollee, the enrollee's health care…
215 ILCS 200/45
Requirements applicable to the personnel who can review appeals
Requirements applicable to the personnel who can review appeals. A health insurance issuer or its contracted utilization review organization must ensure that all appeals are reviewed by a physician when the request is by a physician or a representative of a physician. The physician must: (1) possess a current and valid…
215 ILCS 200/50
Review of prior authorization requirements
Review of prior authorization requirements. A health insurance issuer shall periodically review its prior authorization requirements and consider removal of prior authorization requirements: (1) where a medication or procedure prescribed is customary and properly indicated or is a treatment for the clinical indication…
215 ILCS 200/55
Denial or penalty
Denial or penalty. (a) The health insurance issuer or its contracted utilization review organization may not revoke or further limit, condition, or restrict a previously issued prior authorization approval while it remains valid under this Act. (b) Notwithstanding any other provision of law, if a claim is properly code…
215 ILCS 200/60
Length of prior authorization approval
Length of prior authorization approval. A prior authorization approval shall be valid for the lesser of 6 months after the date the health care professional or health care provider receives the prior authorization approval or the length of treatment as determined by the patient's health care professional or the renewal…
215 ILCS 200/65
Length of prior authorization approval for treatment for chronic or long-term conditions
Length of prior authorization approval for treatment for chronic or long-term conditions. If a health insurance issuer requires a prior authorization for a recurring health care service or maintenance medication for the treatment of a chronic or long-term condition, the approval shall remain valid for the lesser of 12…
215 ILCS 200/70
Continuity of care for enrollees
Continuity of care for enrollees. (a) On receipt of information documenting a prior authorization approval from the enrollee or from the enrollee's health care professional or health care provider, a health insurance issuer shall honor a prior authorization granted to an enrollee from a previous health insurance issuer…
215 ILCS 200/75
Health care services deemed authorized if a health insurance issuer or its contracted utilization review organization fails to comply with the requirements of this Act
Health care services deemed authorized if a health insurance issuer or its contracted utilization review organization fails to comply with the requirements of this Act. A failure by a health insurance issuer or its contracted utilization review organization to comply with the deadlines and other requirements specified…
215 ILCS 200/77
Prior authorization for drug therapies for hereditary bleeding disorders
Prior authorization for drug therapies for hereditary bleeding disorders. Notwithstanding any other provision of law, a health insurance issuer or a contracted utilization review organization may not require a prior authorization for drug therapies approved by the U.S. Food and Drug Administration for the treatment of…
215 ILCS 200/80
Severability
Severability. If any provision of this Act or its application to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of this Act that can be given effect without the invalid provision or application, and to this end the provisions of this Act are declared to be se…
215 ILCS 200/85
Administration and enforcement
Administration and enforcement. (a) The Department shall enforce the provisions of this Act pursuant to the enforcement powers granted to it by law. To enforce the provisions of this Act, the Director is hereby granted specific authority to issue a cease and desist order or require a utilization review organization or…
215 ILCS 200/900
(Amendatory provisions; text omitted)
(Amendatory provisions; text omitted). (Source: P.A. 102-409, eff. 1-1-22; text omitted.)
215 ILCS 200/905
(Amendatory provisions; text omitted)
(Amendatory provisions; text omitted). (Source: P.A. 102-409, eff. 1-1-22; text omitted.)
215 ILCS 200/910
(Amendatory provisions; text omitted)
(Amendatory provisions; text omitted). (Source: P.A. 102-409, eff. 1-1-22; text omitted.)
215 ILCS 200/999
Effective date
Effective date. This Act takes effect January 1, 2022. (Source: P.A. 102-409, eff. 1-1-22.)