Illinois § 30

§ 30.

Exhaustion of internal appeal process. (a) Except as provided in subsection (b) of this Section, a request for an external review shall not be made until the covered person has exhausted the health carrier's internal appeal process. (b) A covered person shall be considered to have exhausted the health carrier's internal appeal process for purposes of this Section if: (1) the covered person or the covered person's authorized representative has filed an appeal under the health carrier's internal appeal process and has not received a written decision on the appeal 30 days following the date the covered person or the covered person's authorized representative files an appeal of an adverse determination that involves a concurrent or prospective review request or 60 days following the date the covered person or the covered person's authorized representative files an appeal of an adverse determination that involves a retrospective review request, except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay; (2) the covered person or the covered person's authorized representative filed a request for an expedited internal review of an adverse determination and has not received a decision on such request from the health carrier within 48 hours, except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay; (3) the health carrier agrees to waive the exhaustion requirement; (4) the covered person has a medical condition in which the timeframe for completion of (A) an expedited internal review of an appeal involving an adverse determination, (B) a final adverse determination, or (C) a standard external review as established in this Act would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; (5) an adverse determination concerns a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's health care provider certifies in writing that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated; in such cases, the covered person or the covered person's authorized representative may request an expedited external review at the same time the covered person or the covered person's authorized representative files a request for an expedited internal appeal involving an adverse determination; the independent review organization assigned to conduct the expedited external review shall determine whether the covered person is required to complete the expedited review of the appeal prior to conducting the expedited external review; or (6) the health carrier has failed to comply with applicable State and federal law governing internal claims and appeals procedures. (Source: P.A. 96-857, eff. 7-1-10; 97-574, eff. 8-26-11.)