Illinois § 45

§ 45.

Requirements applicable to the personnel who can review appeals. A health insurance issuer or its contracted utilization review organization must ensure that all appeals are reviewed 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 to practice medicine in any United States jurisdiction; (2) be in the same or similar specialty as a physician who typically manages the medical condition or disease; (3) be knowledgeable of, and have experience providing, the health care services under appeal; (4) not have been directly involved in making the adverse determination; and (5) consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the health insurance issuer or its contracted utilization review organization by the enrollee's health care professional or health care provider and any medical literature provided to the health insurance issuer or its contracted utilization review organization by the health care professional or health care provider. Notwithstanding the foregoing, a licensed health care professional who satisfies the requirements in this Section may review appeal requests submitted by a health care professional licensed in the same profession. (Source: P.A. 102-409, eff. 1-1-22.)