In one paragraph
The Health Care Protection Act is a broad health insurance reform covering network adequacy, prior authorization, step therapy and short-term plans. Its automated decision provision amends Section 85 of the Managed Care Reform and Patient Rights Act (215 ILCS 134/85) on utilization review programs. Only a clinical peer may make adverse medical necessity determinations. A health care professional, an accredited algorithmic automated process, or both together may certify (approve) medical necessity in line with accreditation standards, and an automated process may be used to refer a case to a clinical peer for a possible denial. Effective January 1, 2025.
Plain-English summary, written with AI assistance. The official text controls.
What it means for business
Health insurers and utilization review organizations can use accredited automated tools to approve care but must keep human clinical peers responsible for denials.
Key provisions
- Accredited algorithmic automated processes may approve (certify) medical necessity
- Adverse determinations must be made by a clinical peer, not an algorithm
- Automated tools may route cases to a clinical peer for possible denial
- Amends 215 ILCS 134/85 (utilization review program registration)
- Effective January 1, 2025
Latest legislative action
Jul 10, 2024. Governor Approved July 10, 2024. Effective Date January 1, 2025. Public Act 103-0650.
Topics and industries
Related topics
Affected industries
This page is general information, not legal advice. Summaries are AI-assisted and may contain errors; read the statute for the controlling text and talk to a lawyer about your situation. Full disclaimer · Report an error