Part 3: How Does the Prior Authorization Reform Act Address Adverse Determinations?

July 9, 2021

During the Spring Legislative Session in Springfield, the General Assembly unanimously approved the Prior Authorization Reform Act (House Bill 711), which has been sent to 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 week’s focus is adverse determinations.

The current problem: Prior authorization denials – or “adverse determinations” – are often made by non-physicians or physicians in different specialty areas who have little or no experience treating the condition for which the prior authorization request is being made. Such reviewers lack the specialized knowledge necessary to appropriately evaluate a prior authorization request.

How House Bill 711 helps: It establishes minimum qualifications for individuals who can deny a prior authorization request, and specifies the information that a utilization review organization must provide at the time of denial, which helps the physician understand what additional information may be needed to support an approval for the service.

Personnel qualified to make adverse determinations:

  • All adverse determinations must be made by a physician when the request is by a physician or on behalf of a physician. The physician must:
    • Possesses a current and valid non-restricted license; and
    • Have experience treating and managing patients with the medical condition or disease for which the healthcare service is being requested.

Requirements for adverse determination:

  • A health insurance issuer or its contracted utilization review organization must provide specific information to the enrollee, the enrollee’s healthcare professional, and the enrollee’s treating healthcare professional when an adverse determination is made, including:
    • The reasons for the adverse determination and related evidence-based criteria, including a description of any missing or insufficient documentation;
    • The right to appeal the adverse determination;
    • Instructions on how to file the appeal; and
    • Additional documentation necessary to support the appeal.

Did you miss the previous installments?

Questions? Please contact ISMS Senior Vice President of Legislative Affairs Erin O'Brien by email.

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