Illinois Compiled Statutes 215 ILCS 134/10 – Definitions
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“Adverse determination” means a determination by a health care plan under Section 45 or by a utilization review program under Section 85 that a health care service is not medically necessary.
“Clinical peer” means a health care professional who is in the same profession and the same or similar specialty as the health care provider who typically manages the medical condition, procedures, or treatment under review.
“Department” means the Department of Insurance.
“Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, regardless of the final diagnosis given, 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:
(1) placing the health of the individual (or, with
“Clinical peer” means a health care professional who is in the same profession and the same or similar specialty as the health care provider who typically manages the medical condition, procedures, or treatment under review.
Terms Used In Illinois Compiled Statutes 215 ILCS 134/10
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- individual: shall include every infant member of the species homo sapiens who is born alive at any stage of development. See Illinois Compiled Statutes 5 ILCS 70/1.36
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
- State: when applied to different parts of the United States, may be construed to include the District of Columbia and the several territories, and the words "United States" may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14
“Department” means the Department of Insurance.
“Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, regardless of the final diagnosis given, 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:
(1) placing the health of the individual (or, with
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respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
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(2) serious impairment to bodily functions;
(3) serious dysfunction of any bodily organ or part;
(4) inadequately controlled pain; or
(5) with respect to a pregnant woman who is having
(3) serious dysfunction of any bodily organ or part;
(4) inadequately controlled pain; or
(5) with respect to a pregnant woman who is having
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contractions:
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(A) inadequate time to complete a safe transfer
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to another hospital before delivery; or
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(B) a transfer to another hospital may pose a
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threat to the health or safety of the woman or unborn child.
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“Emergency medical screening examination” means a medical screening examination and evaluation by a physician licensed to practice medicine in all its branches, or to the extent permitted by applicable laws, by other appropriately licensed personnel under the supervision of or in collaboration with a physician licensed to practice medicine in all its branches to determine whether the need for emergency services exists.
“Emergency services” means, with respect to an enrollee of a health care plan, transportation services, including but not limited to ambulance services, and covered inpatient and outpatient hospital services furnished by a provider qualified to furnish those services that are needed to evaluate or stabilize an emergency medical condition. “Emergency services” does not refer to post-stabilization medical services.
“Enrollee” means any person and his or her dependents enrolled in or covered by a health care plan.
“Health care plan” means a plan, including, but not limited to, a health maintenance organization, a managed care community network as defined in the Illinois Public Aid Code, or an accountable care entity as defined in the Illinois Public Aid Code that receives capitated payments to cover medical services from the Department of Healthcare and Family Services, that establishes, operates, or maintains a network of health care providers that has entered into an agreement with the plan to provide health care services to enrollees to whom the plan has the ultimate obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution. Nothing in this definition shall be construed to mean that an independent practice association or a physician hospital organization that subcontracts with a health care plan is, for purposes of that subcontract, a health care plan.
For purposes of this definition, “health care plan” shall not include the following:
(1) indemnity health insurance policies including
“Emergency services” means, with respect to an enrollee of a health care plan, transportation services, including but not limited to ambulance services, and covered inpatient and outpatient hospital services furnished by a provider qualified to furnish those services that are needed to evaluate or stabilize an emergency medical condition. “Emergency services” does not refer to post-stabilization medical services.
“Enrollee” means any person and his or her dependents enrolled in or covered by a health care plan.
“Health care plan” means a plan, including, but not limited to, a health maintenance organization, a managed care community network as defined in the Illinois Public Aid Code, or an accountable care entity as defined in the Illinois Public Aid Code that receives capitated payments to cover medical services from the Department of Healthcare and Family Services, that establishes, operates, or maintains a network of health care providers that has entered into an agreement with the plan to provide health care services to enrollees to whom the plan has the ultimate obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution. Nothing in this definition shall be construed to mean that an independent practice association or a physician hospital organization that subcontracts with a health care plan is, for purposes of that subcontract, a health care plan.
For purposes of this definition, “health care plan” shall not include the following:
(1) indemnity health insurance policies including
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those using a contracted provider network;
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(2) health care plans that offer only dental or only
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vision coverage;
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(3) preferred provider administrators, as defined in
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Section 370g(g) of the Illinois Insurance Code;
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(4) employee or employer self-insured health benefit
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plans under the federal Employee Retirement Income Security Act of 1974;
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(5) health care provided pursuant to the Workers’
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Compensation Act or the Workers’ Occupational Diseases Act; and
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(6) except with respect to subsections (a) and (b) of
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Section 65 and subsection (a-5) of Section 70, not-for-profit voluntary health services plans with health maintenance organization authority in existence as of January 1, 1999 that are affiliated with a union and that only extend coverage to union members and their dependents.
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“Health care professional” means a physician, a registered professional nurse, or other individual appropriately licensed or registered to provide health care services.
“Health care provider” means any physician, hospital facility, facility licensed under the Nursing Home Care Act, long-term care facility as defined in § 1-113 of the Nursing Home Care Act, or other person that is licensed or otherwise authorized to deliver health care services. Nothing in this Act shall be construed to define Independent Practice Associations or Physician-Hospital Organizations as health care providers.
“Health care services” means any services included in the furnishing to any individual of medical care, or the hospitalization incident to the furnishing of such care, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness or injury including behavioral health, mental health, home health, and pharmaceutical services and products.
“Medical director” means a physician licensed in any state to practice medicine in all its branches appointed by a health care plan.
“Person” means a corporation, association, partnership, limited liability company, sole proprietorship, or any other legal entity.
“Physician” means a person licensed under the Medical Practice Act of 1987.
“Post-stabilization medical services” means health care services provided to an enrollee that are furnished in a licensed hospital by a provider that is qualified to furnish such services, and determined to be medically necessary and directly related to the emergency medical condition following stabilization.
“Stabilization” means, with respect to an emergency medical condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result.
“Utilization review” means the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities.
“Utilization review program” means a program established by a person to perform utilization review.
“Health care provider” means any physician, hospital facility, facility licensed under the Nursing Home Care Act, long-term care facility as defined in § 1-113 of the Nursing Home Care Act, or other person that is licensed or otherwise authorized to deliver health care services. Nothing in this Act shall be construed to define Independent Practice Associations or Physician-Hospital Organizations as health care providers.
“Health care services” means any services included in the furnishing to any individual of medical care, or the hospitalization incident to the furnishing of such care, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness or injury including behavioral health, mental health, home health, and pharmaceutical services and products.
“Medical director” means a physician licensed in any state to practice medicine in all its branches appointed by a health care plan.
“Person” means a corporation, association, partnership, limited liability company, sole proprietorship, or any other legal entity.
“Physician” means a person licensed under the Medical Practice Act of 1987.
“Post-stabilization medical services” means health care services provided to an enrollee that are furnished in a licensed hospital by a provider that is qualified to furnish such services, and determined to be medically necessary and directly related to the emergency medical condition following stabilization.
“Stabilization” means, with respect to an emergency medical condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result.
“Utilization review” means the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities.
“Utilization review program” means a program established by a person to perform utilization review.