Illinois Compiled Statutes 215 ILCS 200/45 – Requirements applicable to the personnel who can review appeals
Current as of: 2024 | Check for updates
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A health insurance issuer or its contracted utilization review organization must ensure that all appeals are reviewed 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
(1) possess a current and valid nonrestricted
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license to practice medicine in any United States jurisdiction;
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(2) be in the same or similar specialty as a
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physician who typically manages the medical condition or disease;
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(3) be knowledgeable of, and have experience
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providing, the health care services under appeal;
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(4) not have been directly involved in making the
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adverse determination; and
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(5) consider all known clinical aspects of the
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health care service under review, including, but not limited to, a review of all pertinent medical records provided to the health insurance issuer or its contracted utilization review organization by the enrollee’s health care professional or health care provider and any medical literature provided to the health insurance issuer or its contracted utilization review organization by the health care professional or health care provider.
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Notwithstanding the foregoing, a licensed health care professional who satisfies the requirements in this Section may review appeal requests submitted by a health care professional licensed in the same profession.
Terms Used In Illinois Compiled Statutes 215 ILCS 200/45
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- United States: may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14