Illinois § 35

§ 35.

Personnel qualified to make adverse determinations of a prior authorization request. A health insurance issuer or its contracted utilization review organization must ensure that all adverse determinations are made by a physician when the request is by a physician or a representative of a physician. The physician must: (1) possess a current and valid nonrestricted license in any United States jurisdiction; and (2) have experience treating and managing patients with the medical condition or disease for which the health care service is being requested. Notwithstanding the foregoing, a licensed health care professional who satisfies the requirements of this Section may make an adverse determination of a prior authorization request submitted by a health care professional licensed in the same profession. (Source: P.A. 102-409, eff. 1-1-22.)