A NEW Illinois law guarantees your right to an external, independent review of denied health insurance claims.
THE HEALTH Carrier External Review Act (Public Act 96- 857), effective July 1, ensures that insurance company decisions to deny a recommended medical treatment are subject to review by a qualified, independent doctor.
PREVIOUSLY, ONLY Illinois consumers enrolled in a Health Maintenance Organization (HMO) had the right to an external, independent review when a claim was denied. The new law requires all health insurers and HMOs to provide the same opportunities for both internal appeals and external reviews of denied claims, extending this important right to millions of additional Illinois consumers.
“THE HEALTH Carrier External Review Act empowers and protects Illinois families and businesses who, after paying hard-earned premium dollars, are all too often denied needed medical treatment," said Michael T. McRaith, director of the Illinois Department of Insurance. "The act also requires greater transparency on the part of health insurance companies in Illinois, representing a significant early step towards reforming the State's health insurance marketplace."
THE NEW law allows consumers to request an external review within four months of receiving notice that a claim or treatment request was denied by the insurance company or HMO. Each case is reviewed by an unbiased doctor who is an expert in the relevant field and who is assigned by an Independent Review Organization approved by the Illinois Department of Insurance. The external review must be paid for entirely by the health insurance company and must be completed within 20 business days. In urgent cases, the review must be completed within 72 to 120 hours.
ADDITIONAL INFORMATION about the new external review process, including a list of approved Independent Review Organizations, is available on the Department' of Insurance’s website at http://insurance.illinois.gov.