Illinois Administrative Code › Title 50 - INSURANCE › Part 2018 - UNIFORM ELECTRONIC PRIOR AUTHORIZATION FORM FOR PRESCRIPTION BENEFITS › Section 2018.30 - Uniform Electronic Prior Authorization Form for Prescription Benefits

Current through Register Vol. 48, No. 28, July 12, 2024
On and after July 1, 2021, an insurer that imposes prior
				authorization requirements on prescription benefits in any health insurance
				coverage shall utilize and accept the uniform electronic prior authorization
				form containing the elements listed in this Section. An insurer shall require
				any person conducting prior authorization of prescription drug benefits on its
				behalf to utilize and accept this form. If any prescribing provider fails to
				use this form to request prior authorization of prescription benefits, the
				insurer will not be subject to the requirements of Section 364.3 of the Code
				for that request. Only the version of the PDF that is posted on the
				Department's website shall satisfy the requirements of this Part. The posted
				PDF shall consist of the following elements:
a) The title, which will be: "Illinois
			 Uniform Electronic Prior Authorization Form for Prescription
			 Benefits".
b) An explanatory
			 introduction, which will contain the following text:
This form is made available for use by prescribing providers to
				initiate a prior authorization request with a commercial health insurance
				issuer ("insurer") regulated by the Illinois Department of Insurance.
"Prior authorization request" means a request for pre-approval
				from an insurer for a specified prescription or quantity of a prescription
				before the prescription is dispensed.
"Prescribing provider" has the meaning ascribed in Section
				364.3 of the Illinois Insurance Code [215 ILCS 5].
"Prescription" has the meaning ascribed in Section 3(e) of the
				Pharmacy Practice Act [225 ILCS 85].
If, upon receipt of a completed and accurate electronic
				prior authorization request from a prescribing provider pursuant to the
				submission of this form, an insurer fails to use or accept the uniform
				electronic prior authorization form or fails to respond within 24 hours (if the
				patient has urgent medication needs), or within 72 hours (if the patient has
				regular medication needs), then the prior authorization request shall be deemed
				to have been granted.
[215
				ILCS 5/364.3(f)] The prescribing
				provider should only provide its direct contact number and initials if
				requesting an Expedited Review Request.
The provisions of this form do not serve as a replacement for
				the step therapy and formulary exception requests that may require additional
				information and forms as provided in Sections 25(a)(3) and 45.1 of the Managed
				Care Reform and Patient Rights Act [215 ILCS 134]. Nothing in this form shall
				be construed to alter or nullify any provisions of federal or Illinois law that
				impose obligations on insurers, prescribing providers, or patients related to
				responsiveness, adjudication and/or appeals.
Prior authorization alone is not a guarantee of benefits or
				payment. Actual availability of benefits is always subject to other
				requirements of the health plan, such as limitations and exclusions, payment of
				premium, and eligibility at the time services are provided. The applicable
				terms of a patient's plan control the benefits that are available. At the time
				the claims are submitted, they will be reviewed in accordance with the terms of
				the plan.
Please refer to the plan's website for additional information
				that may be necessary for review. Please note that sending this form with
				insufficient clinical information may result in an extended review period or
				adverse determination. Insurers may require additional information based on the
				type of prescription drug being requested that may require follow-up inquiries
				with the provider.
PRESCRIBING PROVIDERS: PLEASE SUBMIT THIS FORM TO THE PATIENT'S
				HEALTH PLAN ONLY. Please do not send forms to the Department of
				Insurance.
c) A section to
			 indicate whether the prescribing provider is making a Standard Review Request
			 or an Expedited Review Request. For an Expedited Review Request, the following
			 certification shall appear: "I hereby certify that a standard review period may
			 seriously jeopardize the life or health of the patient or the patient's ability
			 to regain maximum function." The certification shall have spaces for the
			 prescribing provider to add initials and a direct telephone number to contact
			 the prescribing provider.
d) A
			 section entitled "Reason for Request", which will contain options for an
			 Initial Authorization Request, a Renewal Request, and a Dispense As Written
			 (DAW). The section will also have a note that states: "Note: This form does not
			 apply to requests for medical exceptions under Sections 25(a)(3) or 45.1 of the
			 Managed Care Reform and Patient Rights Act [215 ILCS 134]. Please contact the
			 patient's health plan to obtain the appropriate forms."
e) A section entitled "Patient Demographics",
			 which will request the following information:
1) Whether the patient is
			 hospitalized;
2) Patient
			 Name;
3) Patient Date of
			 Birth;
4) Patient Health Plan
			 ID;
5) Patient Health Plan Group
			 Number (if applicable);
6) Patient
			 Address;
7) Patient Phone;
			 and
8) Patient Sex.