The Prior Authorization Reform Act
A BIG Win for Illinois
Updated June 2, 2022
If you think a health insurance company is in violation of the Prior Authorization Reform Act, or any other law or regulation, please file a complaint with the Illinois Department of Insurance (DOI). Taking such action is an important step against onerous health insurance company practices.
In 2018, ISMS initiated a campaign to improve the prior authorization process for patients and physicians in Illinois. We surveyed physicians throughout the state, identifying their top pain points as they try to navigate the prior authorization process and provide timely and appropriate care for their patients.
Based on this survey, your ISMS leadership identified eight key legislative priorities that would guide our efforts to initiate and pass prior authorization reform legislation in Springfield. Thanks to the hard work of ISMS and our grassroots physician members, the Prior Authorization Reform Act passed unanimously in both the Illinois House and Senate, and Governor Pritzker signed it into law on August 19, 2021 as Public Act 102-0409. This law represents a significant victory for Illinois physicians!
ISMS Prior Authorization Reform ScorecardISMS identified eight core areas needed to reform the prior authorization process in Illinois. We are proud to report that all eight priorities were addressed in the final legislation, which applies to health plans regulated by the Illinois Department of Insurance.
- Establish maximum response times for urgent and non-urgent PA requests
PA 102-0409 standardizes response times by requiring health insurance issuers or their utilization
review organizations to respond to PA requests within specific timeframes.
- Nonurgent care: Health insurance issuers or their utilization review organizations will be required to respond to prior authorization requests for nonurgent services within five calendar days of receiving all the necessary information.
- Urgent care: Health insurance issuers or their utilization review organizations will be required to:
- Respond to prior authorization requests for urgent services within 48 hours of receiving all the necessary information.
- Establish a mechanism to ensure healthcare professionals have timely access to someone able to make prior authorization decisions related to urgent care services.