"Act" means the Health Carrier External Review Act [ 215 ILCS
180 ].
"Adverse Determination" means:
A determination by a health carrier or its designee utilization
review organization that, based upon the information provided, a request for a
benefit under the health carrier's health benefit plan, upon application of any
utilization review technique, does not meet the health carrier's requirements
for medical necessity, appropriateness, health care setting, level of care, or
effectiveness or is determined to be experimental or investigational, and the
requested benefit is therefore denied, reduced or terminated, or payment is not
provided or made, in whole or part, for the benefit;
The denial, reduction or termination of, or failure to provide
or make payment, in whole or in part, for, a benefit based on a determination
by a health carrier or its designee utilization review organization that a
preexisting condition was present before the effective date of coverage;
or
A rescission of coverage determination, which does not include
a cancellation or discontinuance of coverage that is attributable to a failure
to timely pay required premiums or contributions towards the cost of
coverage.
"Authorized Representative" means:
A person to whom a covered person has given express written
consent to represent the covered person for purposes of the Act;
A person authorized by law to provide substituted consent for a
covered person;
A family member of the covered person or the covered person's
treating health care professional when the covered person is unable to provide
consent;
A health care provider when the covered person's health benefit
plan requires that a request for a benefit under the plan be initiated by the
health care provider; or
In the case of an urgent care request, a health care provider
with knowledge of the covered person's medical condition.
"Best Evidence" means evidence based on:
Randomized clinical trials;
If randomized clinical trials are not available, then cohort
studies or case-control studies;
If the prior two items are not available, then case-series;
or
If the prior three items are not available, then expert
opinion.
"Case-control Study" means a retrospective evaluation of two
groups of patients with different outcomes to determine which specific
interventions the patients received.
"Case-series" means an evaluation of a series of patients with
a particular outcome, without the use of a control group.
"Clinical Review Criteria" means the written screening
procedures, decision abstracts, clinical protocols, and practice guidelines
used by a health carrier to determine the necessity and appropriateness of
health care services.
"Cohort Study" means a prospective evaluation of 2 groups of
patients with only one group of patients receiving specific
intervention.
"Code" means the Illinois Insurance Code [ 215 ILCS 5 ].
"Concurrent Review" means a review conducted during a patient's
stay or course of treatment in a facility, the office of a health care
professional, or other inpatient or outpatient health care setting.
"Covered Benefits" or "Benefits" means those health care
services to which a covered person is entitled under the terms of a health
benefit plan.
"Covered Person" means a policyholder, subscriber, enrollee, or
other individual participating in a health benefit plan.
"Director" means the Director of the Illinois Department of
Insurance.
"Emergency Medical Condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity, including, but not
limited to, severe pain, 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:
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;
serious impairment to bodily functions; or
serious dysfunction of any bodily organ or part.
"Evidence-based Standard" means the conscientious, explicit and
judicious use of the current best evidence based on an overall systematic
review of the research in making decisions about the care of individual
patients.
"Expert Opinion" means a belief or an interpretation by
specialists with experience in a specific area about the scientific evidence
pertaining to a particular service, intervention, or therapy.
"Facility" means an institution providing health care services
or a health care setting.
"Final Adverse Determination" means an adverse determination
involving a covered benefit that has been upheld by a health carrier, or its
designee utilization review organization, at the completion of the health
carrier's internal grievance process procedures as set forth by the Managed
Care Reform and Patient Rights Act [ 215 ILCS 134 ].
"Health Benefit Plan" means a policy, contract, certificate,
plan, or agreement offered or issued by a health carrier to provide, deliver,
arrange for, pay for, or reimburse any of the costs of health care
services.
"Health Care Provider" or "Provider" means a physician,
hospital facility, or other health care practitioner licensed, accredited, or
certified to perform specified health care services consistent with State law,
responsible for recommending health care services on behalf of a covered
person.
"Health Care Services" means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition, illness, injury,
or disease.
"Health Carrier" means an entity subject to the insurance laws
and regulations of this State, or subject to the jurisdiction of the Director,
that contracts or offers to contract to provide, deliver, arrange for, pay for,
or reimburse any of the costs of health care services, including a sickness and
accident insurance company, a health maintenance organization, or any other
entity providing a plan of health insurance, health benefits, or health care
services. "Health carrier" also means Limited Health Service Organizations
(LHSO) and Voluntary Health Service Plans.
"Health Information" means information or data, whether oral or
recorded in any form or medium, and personal facts or information about events
or relationships that relate to:
The past, present, or future physical, mental, or behavioral
health or condition of an individual or a member of the individual's
family;
The provision of health care services to an individual;
or
Payment for the provision of health care services to an
individual.
"Independent Review Organization" or "IRO" means an entity that
conducts independent external reviews of adverse determinations and final
adverse determinations.
"Medical Necessity" means health care services and supplies
provided by a health care provider, appropriate to the evaluation and treatment
of a disease, condition, illness or injury and consistent with the applicable
standard of care, including the evaluation of experimental and/or
investigational services, procedures, drugs or devices.
"Medical or Scientific Evidence" means evidence found in the
following sources:
Peer-reviewed scientific studies published in or accepted for
publication by medical journals that meet nationally recognized requirements
for scientific manuscripts and that submit most of their published articles for
review by experts who are not part of the editorial staff;
Peer-reviewed medical literature, including literature relating
to therapies reviewed and approved by a qualified institutional review board,
biomedical compendia, and other medical literature that meets the criteria of
the National Institutes of Health's Library of Medicine for indexing in Index
Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus
(EMBASE);
Medical journals recognized by the Secretary of Health and
Human Services under section 1861(t)(2) of the federal Social Security Act (
42 USC
1861(t)(2) );
The following standard reference compendia:
The American Hospital Formulary Service Drug
Information;
Drug Facts and Comparisons;
The American Dental Association Accepted Dental Therapeutics;
and
The United States Pharmacopoeia Drug Information;
Findings, studies, or research conducted by or under the
auspices of federal government agencies and nationally recognized federal
research institutes, including:
The federal Agency for Healthcare Research and Quality;
The National Institutes of Health;
The National Cancer Institute;
The National Academy of Sciences;
The Centers for Medicare & Medicaid Services;
The federal Food and Drug Administration; and
Any national board recognized by the National Institutes of
Health for the purpose of evaluating the medical value of health care services;
or
Any other medical or scientific evidence that is comparable to
the sources listed in this definition.
Medical necessity determinations for substance use
disorders shall be made in accordance with appropriate patient placement
criteria established by the American Society of Addiction Medicine [
215 ILCS
5/370c(b)(3) ].
"Member" means a covered person as defined by this Part.
"Person" means an individual, a corporation, a partnership, an
association, a joint venture, a joint stock company, a trust, an unincorporated
organization, any similar entity, or any combination of the foregoing.
"Prospective Review" means a review conducted prior to an
admission or the provision of a health care service or a course of treatment in
accordance with a health carrier's requirement that the health care service or
course of treatment, in whole or in part, be approved prior to its
provision.
"Protected Health Information" means health information that
identifies an individual who is the subject of the information, or with respect
to which there is a reasonable basis to believe that the information could be
used to identify an individual.
"Randomized Clinical Trial" means a controlled, prospective
study of patients that have been randomized into an experimental group and a
control group at the beginning of the study with only the experimental group of
patients receiving a specific intervention, which includes study of the groups
for variables and anticipated outcomes over time.
"Retrospective Review" means any review of a request for a
benefit that is not a concurrent or prospective review request. "Retrospective
Review" does not include the review of a claim that is limited to veracity of
documentation or accuracy of coding.
"Utilization Review" means the evaluation of the medical
necessity, appropriateness, and efficiency of the use of health care services,
procedures, and facilities.
"Utilization Review Organization" means a utilization review
program as defined in the Managed Care Reform and Patient Rights
Act.
