305 ILCS 5/5-30.18 — Illinois Code / Chapter 305 / Act 5 / Section 5-30.18
Section 5-30.18
Status: in_force

(305 ILCS 5/5-30.18) (Section scheduled to be repealed on December 31, 2030) Sec. 5-30.18. Service authorization program performance. (a) Definitions. As used in this Section: "Gold Card provider" means a provider identified by each Medicaid Managed Care Organization (MCO) as qualified under the guidelines outlined by the Department in accordance with subsection (c) and thereby granted a service authorization exemption when ordering a health care service. "Health care service" means any medical or behavioral health service covered under the medical assistance program that is rendered in the inpatient or outpatient hospital setting, including hospital-based clinics, and subject to review under a service authorization program. "Provider" means an individual actively enrolled in the medical assistance program and licensed or otherwise authorized to order, prescribe, refer, or render health care services in this State, and, as determined by the Department, may also include hospitals that submit service authorization requests. "Service authorization exemption" means an exception granted by a Medicaid MCO to a provider under which all service authorization requests for covered health care services, excluding pharmacy services and durable medical equipment, are automatically deemed to be medically necessary, clinically appropriate, and approved for reimbursement as ordered. "Service authorization program" means any utilization review, utilization management, peer review, quality review, or other medical management activity conducted in advance of, concurrent to, or after the provision of a health care service by a Medicaid MCO, either directly or through a contracted utilization review organization (URO), including, but not limited to, prior authorization, pre-certification, certification of admission, concurrent review, and retrospective review of health care services. "Service authorization request" means a request by a provider to a service authorization program to determine whether a health care service that is otherwise covered under the medical assistance program meets the reimbursement requirements established by the Medicaid MCO, or its contracted URO, for medically necessary, clinically appropriate care and to issue a service authorization determination. "Utilization review organization" or "URO" means a managed care organization or other entity that has established or administers one or more service authorization programs. (b) In consultation with the Medicaid MCOs, a statewide association representing managed care organizations, a statewide association representing the majority of Illinois hospitals, and a statewide association representing physicians, the Department shall in accordance with the Illinois Administrative Procedure Act, adopt administrative rules no later than July 1, 2026, consistent with this Section, to require each Medicaid MCO to identify Gold Card providers with such identification initially being effective for health care services provided on and after July 1, 2026. (c) The Department shall adopt rules, in accordance with the Illinois Administrative Procedure Act, to implement this Section that include, but are not limited to, the following provisions: (1) Require each Medicaid MCO to provide a service authorization exemption to a provider