§ 20 — Disclosure and review of prior authorization requirements

Illinois § 20

• Jurisdiction: Illinois
• Topic: REGULATION
• Ch. 215: INSURANCE
• Act 215 ILCS 200/: Prior Authorization Reform Act.

Text

(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 insurance issuer shall publish this list on its public website without requiring a member of the general public to create any account or enter any credentials to access it. The list described in this subsection is not required to contain the clinical review criteria applicable to these services. (b) A health insurance issuer shall make any current prior authorization requirements and restrictions, including the written clinical review criteria, readily accessible and conspicuously posted on its website to enrollees, health care professionals, and health care providers. Content published by a third party and licensed for use by a health insurance issuer or its contracted utilization review organization may be made available through the health insurance issuer's or its contracted utilization review organization's secure, password-protected website so long as the access requirements of the website do not unreasonably restrict access. Requirements shall be described in detail, written in easily understandable language, and readily available to the health care professional and health care provider at the point of care. The website shall indicate for each service subject to prior authorization: (1) when prior authorization became required for policies issued or delivered in Illinois, including the effective date or dates and the termination date or dates, if applicable, in Illinois; (2) the date the Illinois-specific requirement was listed on the health insurance issuer's or its contracted utilization review organization's website; (3) where applicable, the date that prior authorization was removed for Illinois; and (4) where applicable, access to a standardized electronic prior authorization request transaction process. (c) The clinical review criteria must: (1) be based on nationally recognized, generally accepted standards except where State law provides its own standard; (2) be developed in accordance with the current standards of a national medical accreditation entity; (3) ensure quality of care and access to needed health care services; (4) be evidence-based; (5) be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and (6) be evaluated and updated, if necessary, at least annually. (d) A health insurance issuer shall not deny a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date of service on the claim. (e) A health insurance issuer or its contracted utilization review organization shall not deem as incidental or deny supplies or health care services that are routinely used as part of a health care service when: (1) an associated health care service has received prior authorization; or (2) prior authorization for the health care service is not required. (f) If a health insurance issuer intends either to implement a new prior authorization requirement or restriction or amend an existing requirement or restriction, the health insurance issuer shall provide contracted health care professionals and contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented. The written notice may be provided in an electronic format, including email or facsimile, if the health care professional or health care provider has agreed in advance to receive notices electronically. The health insurance issuer shall ensure that the new or amended requirement is not implemented unless the health insurance issuer's or its contracted utilization review organization's website has been updated to reflect the new or amended requirement or restriction. (g) Entities using prior authorization shall make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. The statistics must be updated annually and include all of the following information: (1) a list of all health care services, including medications, that are subject to prior authorization; (2) the total number of prior authorization requests received; (3) the number of prior authorization requests denied during the previous plan year by the health insurance issuer or its contracted utilization review organization with respect to each service described in paragraph (1) and the top 5 reasons for denial; (4) the number of requests described in paragraph (3) that were appealed, the number of the appealed requests that upheld the adverse determination, and the number of appealed requests that reversed the adverse determination; (5) the average time between submission and response; and (6) any other information as the Director determines appropriate.

Legislative History

(Source: P.A. 102-409, eff. 1-1-22; 103-650, eff. 1-1-25 .)