Ill. Admin. Code tit. 50 § 4520.130

Current through Register Vol. 48, No. 45, November 8, 2024

Section 4520.130 - Registration of Utilization Review Organizations

a) Registration: On or after July 1, 2000, a URO may not conduct utilization review for persons subject to Section 85 of the Act unless the URO has registered with the Director. An application for registration shall be made using the standard form available on the Department website (https://insurance.illinois.gov), and must be signed by an officer or director of the URO. Initial registration applications shall be deemed approved unless the Director finds the application to be noncompliant with either the standards set forth in Section 85 of the Act or this Part.

b) The application for registration shall include, but not be limited to, the following information: applicant's identifying and contact information; applicant's agent for service of process in Illinois; applicant's accreditation status; signed affirmation by an officer or director; and for each utilization review program: contact information and business hours; organization and governing structure; number of reviews in Illinois for the current and previous years; description of the grievance process; written policies and procedures for protection of confidential information; and biographical information for officers and directors. The Department will accept the biographical affidavit, and any supplement to that affidavit, that is obtained from the website of the National Association of Insurance Commissioners (NAIC) or the Department.

c) Fees: A URO must register with the Director every two years. A fee of $3,000 must be submitted with each application or renewal unless the URO is accredited by URAC (formerly Utilization Review Accreditation Commission), the National Committee for Quality Assurance (NCQA), The Joint Commission (JCAHO), or the Accreditation Association for Ambulatory Health Care (AAAHC), in which case the fee is $1500.

d) Any material changes in the information filed pursuant to this Part shall be filed with the Director within 30 days after the change. Loss of accreditation status will require re-registration and payment of a $3000 fee pursuant to subsections (a) and (b).

e) Renewals and Appeals:

1) A registered URO may continue to operate, if the application and fee have been filed 30 days prior to the renewal date, until the renewal is denied or issued by the Director.

2) If the renewal application and fee are not received prior to the renewal date, the registration will automatically expire and the URO must re-register and pay a fee pursuant to subsections (a) and (b).

3) If an application for registration or renewal is denied under this Part, the applicant may appeal that denial by requesting a hearing under Article 10 of the Illinois Administrative Procedure Act [5 ILCS 100 ] and 50 Ill. Adm. Code 2402. A petition for hearing must be postmarked no later than 30 days after the date of initial denial. A hearing shall be scheduled within 45 days after the petition is filed with the Director. A decision by the Director shall be rendered within 60 days after the close of the hearing.

Ill. Admin. Code tit. 50, § 4520.130

Recodified from 5420.130 at 41 Ill. Reg. 4982.

Amended at 42 Ill. Reg. 20417, effective 11/1/2018

Amended at 43 Ill. Reg. 11479, effective 9/24/2019

Amended at 46 Ill. Reg. 9881, effective 5/31/2022