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: (1) possess a current and valid nonrestricted license in any United States jurisdiction; and (2) have experience treating and managing patients with the medical condition or disease for which the health care service is being requested. Notwithstanding the foregoing, a licensed health care professional who satisfies the requirements of this Section may make an adverse determination of a prior authorization request submitted by a health care professional licensed in the same profession.
215 ILCS 200/35
Personnel qualified to make adverse determinations of a prior authorization request
Known as the Prior Authorization Reform Act
The act spans §§ 215-200-1 to 215-200-999 (23 sections).
P.A. 102-409, eff. 1-1-22.
Official source: Illinois General Assembly. Reproduced from public-domain Illinois statutes; confirm against the official source for the current text. Not legal advice.