Understanding Recent Changes to the Illinois Mental Health and
Developmental Disabilities Code

NEW HEALTH INSURANCE RULE: HEALTH CARRIER EXTERNAL REVIEW
The Illinois Department of Insurance adopted a new Part titled, “Health Carrier External Review” effective July 16, 2010.

This Rule provides for independent review of health insurers’ decisions denying claims.  If an insurance company (individual and group major medical health insurance policies) or an HMO determines treatment is not medically necessary, and denies pre-certification or denies a claim following treatment, the insured has a right to an external, independent review of the denied health insurance claim.  The external reviews will be conducted by unbiased and qualified physicians, selected by nationally-accredited independent review organizations approved by the Department of Insurance. The entire cost of an external review will be paid for by the health insurance company or HMO. Specific time deadlines are included in the rules.  These rules will be important for your patients if coverage for their treatment by you is denied. 
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