215 ILCS 180/10
For the purposes of this Act:
"Adverse determination" means:
"Adverse determination" includes unilateral determinations that replace the requested health care service with an approval of an alternative health care service without the agreement of the covered person or the covered person's attending provider for the requested health care service, or that condition approval of the requested service on first trying an alternative health care service, either if the request was made under a medical exceptions procedure, or if all of the following are true: (1) the requested service was not excluded by name, description, or service category under the written terms of coverage, (2) the alternative health care service poses no greater risk to the patient based on generally accepted standards of care, and (3) the alternative health care service is at least as likely to produce the same or better effect on the covered person's health as the requested service based on generally accepted standards of care. "Adverse determination" includes determinations made based on any source of health information pertaining to the covered person that is used to deny, reduce, replace, condition, or terminate the benefit or payment. "Adverse determination" includes determinations made in response to a request for authorization when the request was submitted by the health care provider regardless of whether the provider gave notice to or obtained the consent of the covered person or authorized representative to file the request. "Adverse determination" does not include substitutions performed under Section 19.5 or 25 of the Pharmacy Practice Act.
"Authorized representative" means:
"Best evidence" means evidence based on:
"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.
"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 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:
"Emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition.
"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 or as set forth for any additional authorization or internal appeal process provided by contract between the health carrier and the provider. "Final adverse determination" includes determinations made in an appeal of a denial of prior authorization when the appeal was submitted by the health care provider regardless of whether the provider gave notice to or obtained the consent of the covered person or authorized representative to file an internal appeal.
"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:
"Independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.
"Medical or scientific evidence" means evidence found in the following sources:
"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 (i) that identifies an individual who is the subject of the information; or (ii) 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" has the meaning provided by the Managed Care Reform and Patient Rights Act.
"Utilization review organization" means a utilization review program as defined in the Managed Care Reform and Patient Rights Act.
215 ILCS 180/10