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Part 5: How Does the Prior Authorization Reform Act Add Accountability to the Prior Authorization Process?

July 23, 2021

Part 5: How Does the Prior Authorization Reform Act Add Accountability to the Prior Authorization Process?

During the Spring Legislative Session in Springfield, the General Assembly unanimously approved the Prior Authorization Reform Act (House Bill 711), which awaits action by Governor Pritzker. This top ISMS initiative requires that substantive and important changes be made to insurer prior authorization (PA) practices.

Physician Advocate is taking a deep dive into the various components of this important legislation. This  final story in the series spotlights accountability protections under House Bill 711.


The current problem: Utilization review programs treat PA requests in a piecemeal fashion, without considering related supplies or services that are needed for successful outcomes for which a PA request has been submitted.

Similarly, insurers may place further restrictions on a service after a PA approval has been made, or even deny payment for services for which a PA approval has been received.

How House Bill 711 helps: The legislation would prevent state-regulated insurers from changing their own rules midstream. For example, once a prior authorization request is approved, it would not be able to be revoked except under certain circumstances; a covered service that receives PA approval and is billed appropriately must be paid. House Bill 711 would also encourage state-regulated health plans to require fewer PA approvals by requiring plans to periodically re-assess their PA requirements.

  • Utilization review organizations would be prohibited from denying supplies or healthcare services that are routinely used as part of the service for which a prior authorization has been obtained.
     
  • State-regulated health insurance issuers and utilization review programs would be prohibited from revoking or further limiting, conditioning or restricting a prior authorization while it remains valid.
     
  • State-regulated health insurance issuers would be required to make payment according to the terms of coverage on properly coded and submitted claims for services for which prior authorization approval was received, with certain exceptions.
     
  • Utilization review organizations would be prohibited from denying a claim for failure to obtain prior authorization if the PA requirement was not in effect on the date of service.

Did you miss previous installments of our series “Unpacking Prior Authorization Reform”?

If you have questions, please contact ISMS Senior Vice President of State Legislative Affairs Erin O'Brien  by email

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