IL HB2472: INS-ADVERSE DETERMINATION

In one paragraph

Illinois' Public Act 103-0656 (HB 2472) is a broad health insurance act (explanation-of-benefits statements, prior authorization penalties, utilization review accreditation, adverse determinations). Its AI-related part covers algorithmic automated processes in utilization review: even when a plan or utilization review program uses one, only a clinical peer may make an adverse medical necessity determination or review an appeal. Programs using such processes must use objective, evidence-based criteria compliant with URAC or NCQA standards, set by board-certified physicians, and file proof with their registration. Approved July 19, 2024; effective January 1, 2025.

Plain-English summary, written with AI assistance. The official text controls.

What it means for business

Health insurers, HMOs and utilization review organizations in Illinois that use algorithmic tools in medical necessity review: only a clinical peer may issue adverse determinations or decide appeals, and tools need URAC- or NCQA-compliant, physician-set criteria, with proof filed at registration.

Key provisions

1. 1Broad act amending the Illinois Insurance Code, the Managed Care Reform and Patient Rights Act, the Health Carrier External Review Act, the Prior Authorization Reform Act and other health plan laws; its AI-related changes concern algorithmic automated processes in utilization review
2. 2Utilization review now expressly includes any evaluation based on an algorithmic automated process (Managed Care Reform and Patient Rights Act, Sec. 10)
3. 3Sec. 45(i): even if a health care plan or other utilization review program uses an algorithmic automated process for medical necessity review, only a clinical peer (a professional in the same profession and same or similar specialty as the provider who typically manages the condition) may make an adverse determination based on medical necessity or review an appeal
4. 4Sec. 85(e)(2): only a clinical peer (previously any health care professional) may make adverse medical necessity determinations; a health care professional, an accredited algorithmic automated process, or both may certify medical necessity, and an accredited process may refer a case to a clinical peer for a potential adverse determination
5. 5Sec. 85(b-10): utilization review programs that use algorithmic automated processes to decide whether to render adverse determinations must use objective, evidence-based criteria compliant with URAC or NCQA Health Utilization Management Standards and give the Department of Insurance proof of compliance with each registration and renewal
6. 6Registration materials must include policies ensuring licensed physicians with relevant board certifications set all criteria the automated process uses, and a program integrity system in which such physicians verify the process and its corrections give results consistent with the criteria, before new or revised criteria are used and when implementation errors are found
7. 7Other changes: utilization review programs must show current accreditation (URAC, NCQA or another authorized accreditor) when registering every 2 years; prior authorization penalties on enrollees are capped at the lesser of the service's cost or $1,000 per occurrence; no more than one prior authorization for the same instance of a service
8. 8Approved July 19, 2024 (Public Act 103-0656); effective January 1, 2025

Latest legislative action

Jul 19, 2024. Public Act . . . . . . . . . 103-0656

Sponsors (showing 5 of 30)

Roll call votes (showing 3 of 5)

Amendments (2)

• House Amendment 001 Not adopted 2024-03-14
• House Amendment 002 Not adopted 2024-04-16