Illinois § 55

§ 55.

Denial or penalty. (a) The health insurance issuer or its contracted utilization review organization may not revoke or further limit, condition, or restrict a previously issued prior authorization approval while it remains valid under this Act. (b) Notwithstanding any other provision of law, if a claim is properly coded and submitted timely to a health insurance issuer, the health insurance issuer shall make payment according to the terms of coverage on claims for health care services for which prior authorization was required and approval received before the rendering of health care services, unless one of the following occurs: (1) it is timely determined that the enrollee's health care professional or health care provider knowingly provided health care services that required prior authorization from the health insurance issuer or its contracted utilization review organization without first obtaining prior authorization for those health care services; (2) it is timely determined that the health care services claimed were not performed; (3) it is timely determined that the health care services rendered were contrary to the instructions of the health insurance issuer or its contracted utilization review organization or delegated reviewer if contact was made between those parties before the service being rendered; (4) it is timely determined that the enrollee receiving such health care services was not an enrollee of the health care plan; or (5) the approval was based upon a material misrepresentation by the enrollee, health care professional, or health care provider; as used in this paragraph (5), "material" means a fact or situation that is not merely technical in nature and results or could result in a substantial change in the situation. (c) Nothing in this Section shall preclude a utilization review organization or a health insurance issuer from performing post-service reviews of health care claims for purposes of payment integrity or for the prevention of fraud, waste, or abuse. (d) If a health insurance issuer imposes a monetary penalty on the enrollee for the enrollee's, health care professional's, or health care provider's failure to obtain any form of prior authorization for a health care service, the penalty may not exceed the lesser of: (1) the actual cost of the health care service; or (2) $1,000 per occurrence in addition to the plan cost-sharing provisions. (e) A health insurance issuer may not require both the enrollee and the health care professional or health care provider to obtain any form of prior authorization for the same instance of a health care service, nor otherwise require more than one prior authorization for the same instance of a health care service. (Source: P.A. 102-409, eff. 1-1-22; 103-656, eff. 1-1-25.)