Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Section 4530.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Act" means the Health Carrier External Review Act [ 215 ILCS
				180 ].
"Adverse Determination" means:
A determination by a health carrier or its designee utilization
				review organization that, based upon the information provided, a request for a
				benefit under the health carrier's health benefit plan, upon application of any
				utilization review technique, does not meet the health carrier's requirements
				for medical necessity, appropriateness, health care setting, level of care, or
				effectiveness or is determined to be experimental or investigational, and the
				requested benefit is therefore denied, reduced or terminated, or payment is not
				provided or made, in whole or part, for the benefit;
The denial, reduction or termination of, or failure to provide
				or make payment, in whole or in part, for, a benefit based on a determination
				by a health carrier or its designee utilization review organization that a
				preexisting condition was present before the effective date of coverage;
				or
A rescission of coverage determination, which does not include
				a cancellation or discontinuance of coverage that is attributable to a failure
				to timely pay required premiums or contributions towards the cost of
				coverage.
"Authorized Representative" means:
A person to whom a covered person has given express written
				consent to represent the covered person for purposes of the Act;
A person authorized by law to provide substituted consent for a
				covered person;
A family member of the covered person or the covered person's
				treating health care professional when the covered person is unable to provide
				consent;
A health care provider when the covered person's health benefit
				plan requires that a request for a benefit under the plan be initiated by the
				health care provider; or
In the case of an urgent care request, a health care provider
				with knowledge of the covered person's medical condition.
"Best Evidence" means evidence based on:
Randomized clinical trials;
If randomized clinical trials are not available, then cohort
				studies or case-control studies;
If the prior two items are not available, then case-series;
				or
If the prior three items are not available, then expert
				opinion.
"Case-control Study" means a retrospective evaluation of two
				groups of patients with different outcomes to determine which specific
				interventions the patients received.
"Case-series" means an evaluation of a series of patients with
				a particular outcome, without the use of a control group.
"Clinical Review Criteria" means the written screening
				procedures, decision abstracts, clinical protocols, and practice guidelines
				used by a health carrier to determine the necessity and appropriateness of
				health care services.
"Cohort Study" means a prospective evaluation of 2 groups of
				patients with only one group of patients receiving specific
				intervention.
"Code" means the Illinois Insurance Code [ 215 ILCS 5 ].
"Concurrent Review" means a review conducted during a patient's
				stay or course of treatment in a facility, the office of a health care
				professional, or other inpatient or outpatient health care setting.
"Covered Benefits" or "Benefits" means those health care
				services to which a covered person is entitled under the terms of a health
				benefit plan.
"Covered Person" means a policyholder, subscriber, enrollee, or
				other individual participating in a health benefit plan.
"Director" means the Director of the Illinois Department of
				Insurance.
"Emergency Medical Condition" means a medical condition
				manifesting itself by acute symptoms of sufficient severity, including, but not
				limited to, severe pain, 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:
placing the health of the individual or, with respect to a
				pregnant woman, the health of the woman or her unborn child, in serious
				jeopardy;
serious impairment to bodily functions; or
serious dysfunction of any bodily organ or part.
"Evidence-based Standard" means the conscientious, explicit and
				judicious use of the current best evidence based on an overall systematic
				review of the research in making decisions about the care of individual
				patients.
"Expert Opinion" means a belief or an interpretation by
				specialists with experience in a specific area about the scientific evidence
				pertaining to a particular service, intervention, or therapy.
"Facility" means an institution providing health care services
				or a health care setting.
"Final Adverse Determination" means an adverse determination
				involving a covered benefit that has been upheld by a health carrier, or its
				designee utilization review organization, at the completion of the health
				carrier's internal grievance process procedures as set forth by the Managed
				Care Reform and Patient Rights Act [ 215 ILCS 134 ].
"Health Benefit Plan" means a policy, contract, certificate,
				plan, or agreement offered or issued by a health carrier to provide, deliver,
				arrange for, pay for, or reimburse any of the costs of health care
				services.
"Health Care Provider" or "Provider" means a physician,
				hospital facility, or other health care practitioner licensed, accredited, or
				certified to perform specified health care services consistent with State law,
				responsible for recommending health care services on behalf of a covered
				person.
"Health Care Services" means services for the diagnosis,
				prevention, treatment, cure, or relief of a health condition, illness, injury,
				or disease.
"Health Carrier" means an entity subject to the insurance laws
				and regulations of this State, or subject to the jurisdiction of the Director,
				that contracts or offers to contract to provide, deliver, arrange for, pay for,
				or reimburse any of the costs of health care services, including a sickness and
				accident insurance company, a health maintenance organization, or any other
				entity providing a plan of health insurance, health benefits, or health care
				services. "Health carrier" also means Limited Health Service Organizations
				(LHSO) and Voluntary Health Service Plans.
"Health Information" means information or data, whether oral or
				recorded in any form or medium, and personal facts or information about events
				or relationships that relate to:
The past, present, or future physical, mental, or behavioral
				health or condition of an individual or a member of the individual's
				family;
The provision of health care services to an individual;
				or
Payment for the provision of health care services to an
				individual.
"Independent Review Organization" or "IRO" means an entity that
				conducts independent external reviews of adverse determinations and final
				adverse determinations.
"Medical Necessity" means health care services and supplies
				provided by a health care provider, appropriate to the evaluation and treatment
				of a disease, condition, illness or injury and consistent with the applicable
				standard of care, including the evaluation of experimental and/or
				investigational services, procedures, drugs or devices.
"Medical or Scientific Evidence" means evidence found in the
				following sources:
Peer-reviewed scientific studies published in or accepted for
				publication by medical journals that meet nationally recognized requirements
				for scientific manuscripts and that submit most of their published articles for
				review by experts who are not part of the editorial staff;
Peer-reviewed medical literature, including literature relating
				to therapies reviewed and approved by a qualified institutional review board,
				biomedical compendia, and other medical literature that meets the criteria of
				the National Institutes of Health's Library of Medicine for indexing in Index
				Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus
				(EMBASE);
Medical journals recognized by the Secretary of Health and
				Human Services under section 1861(t)(2) of the federal Social Security Act (
				42 USC
				1861(t)(2) );
The following standard reference compendia:
The American Hospital Formulary Service Drug
				Information;
Drug Facts and Comparisons;
The American Dental Association Accepted Dental Therapeutics;
				and
The United States Pharmacopoeia Drug Information;
Findings, studies, or research conducted by or under the
				auspices of federal government agencies and nationally recognized federal
				research institutes, including:
The federal Agency for Healthcare Research and Quality;
The National Institutes of Health;
The National Cancer Institute;
The National Academy of Sciences;
The Centers for Medicare & Medicaid Services;
The federal Food and Drug Administration; and
Any national board recognized by the National Institutes of
				Health for the purpose of evaluating the medical value of health care services;
				or
Any other medical or scientific evidence that is comparable to
				the sources listed in this definition.
Medical necessity determinations for substance use
				disorders shall be made in accordance with appropriate patient placement
				criteria established by the American Society of Addiction Medicine
[
				215 ILCS
				5/370c(b)(3) ].
"Member" means a covered person as defined by this Part.
"Person" means an individual, a corporation, a partnership, an
				association, a joint venture, a joint stock company, a trust, an unincorporated
				organization, any similar entity, or any combination of the foregoing.
"Prospective Review" means a review conducted prior to an
				admission or the provision of a health care service or a course of treatment in
				accordance with a health carrier's requirement that the health care service or
				course of treatment, in whole or in part, be approved prior to its
				provision.
"Protected Health Information" means health information that
				identifies an individual who is the subject of the information, or with respect
				to which there is a reasonable basis to believe that the information could be
				used to identify an individual.
"Randomized Clinical Trial" means a controlled, prospective
				study of patients that have been randomized into an experimental group and a
				control group at the beginning of the study with only the experimental group of
				patients receiving a specific intervention, which includes study of the groups
				for variables and anticipated outcomes over time.
"Retrospective Review" means any review of a request for a
				benefit that is not a concurrent or prospective review request. "Retrospective
				Review" does not include the review of a claim that is limited to veracity of
				documentation or accuracy of coding.
"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" means a utilization review
				program as defined in the Managed Care Reform and Patient Rights
				Act.