Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Act" means the Managed Care Reform and Patient Rights Act [
				215 ILCS 134 ].
"Code" means the Illinois Insurance Code [ 215 ILCS 5 ].
"Department" means the Illinois Department of Insurance.
"Director" means the Director of the Illinois Department of
				Insurance.
"Health Care Plan" means a plan 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:
indemnity health insurance policies including those using a
				contracted provider network;
health care plans that offer only dental or only vision
				coverage;
preferred provider administrators, as defined in Section
				370g(g) of the Illinois Insurance Code;
employee or employer self-insured health benefit plans under
				the federal Employee Retirement Income Security Act of 1974;
health care provided pursuant to the Workers' Compensation Act
				or the Workers' Occupational Diseases Act; and
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.
"Health Care Provider" means any physician, hospital facility,
				nursing home or other person that is licensed or otherwise authorized to
				deliver health care services. Nothing in the Act shall be construed to define
				independent practice associations or physician hospital organizations as health
				care providers.
"Long-Standing Relationship" means the continuous relationship
				between an enrollee and his or her primary care physician of not less than 5
				years; except in the case of a child 5 years or under who has had a continuous
				relationship with the same primary care physician since birth, placement for
				adoption, guardianship or foster care.
"Managed Care Organization" or "MCO" means a partnership,
				association, corporation or other legal entity, including but not limited to
				individual practice associations (IPAs) and Physician Hospital Organizations
				(PHOs), which delivers or arranges for the delivery of health care services
				through providers it has contracted with or otherwise made arrangements with to
				furnish such health care services.
"Nursing Home" means a skilled nursing care facility that is
				subject to licensure by the Illinois Department of Public Health under the
				Nursing Home Care Act [ 210 ILCS 45 ].
"Ongoing Course of Treatment" means the treatment of a
				condition or disease that requires repeated health care services pursuant to a
				plan of treatment by a physician because of the potential for changes in the
				therapeutic regimen.
"Person" means a corporation, association, partnership, limited
				liability company, sole proprietorship, or any other legal entity.
"Referral Arrangement" means that, for each referral or
				standing referral, a referral arrangement exists between a participating
				primary care physician and a participating specialist physician or a
				participating health care provider when a participating primary care physician
				makes a referral of an enrollee for that referral or standing referral to a
				participating specialist physician or participating health care
				provider.
"Standing Referral" means a written referral from the primary
				care physician for an ongoing course of treatment pursuant to a treatment plan
				specifying needed services and time frames developed by a specialist in
				consultation with the primary care physician and in accordance with procedures
				developed by the health care plan.
"Utilization Review" means the evaluation of the medical
				necessity, appropriateness, and efficiency of the use of health care services,
				procedures, and facilities.
"Utilization Review Organization" or "URO" means an entity that
				has established one or more utilization review programs. This definition does
				not include:
persons providing utilization review program services only to
				the federal government;
self-insured health plans under the Federal Employee Retirement
				Income Security Act of 1974 (ERISA); however, this Part does not apply to
				persons conducting a utilization review program on behalf of these health
				plans;
hospitals and medical groups performing utilization review
				activities for internal purposes; however, this Part does apply when the
				hospital or medical group is conducting utilization review for another
				person.
"Utilization Review Program" means a program established by a
				person to perform utilization review.