Utilization Review Licensing in Illinois

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Illinois. For assistance with licensing, please contact us to learn about our software and managed license services.

Illinois Independent Review Organization Registration

Agency:Illinois Department of Insurance
Law:

215 ILCS 180/50

Registered Agent (Special Agency) Required?Yes

Initial Registration

Filing Method:

Online

Agency Fee:

$1,000 for accredited organizations or $1,500 for unaccredited organizations.

Required Attachments:
  • For each Independent Review Program submit:
    • The name, address, telephone number and hours of operation for the independent review program
    • The organization and governing structure of the independent review program
    • The number of reviews in Illinois for which an independent review is conducted by each independent review program for the current year
    • Number of reviews in Illinois for which an independent review was conducted for the previous calendar year for each independent review program
    • A copy of your most recent certificate from American Accreditation Healthcare Commission (URAC) Standards for Independent Review Organizations, if applicable
    • Written policies and procedures for protection of confidential information according to applicable State and federal laws for each independent review program
    • Biographical information for organization officers and directors
    • A list of all contracted reviewers, the physician's license number of each reviewer and his or her contact information and area of clinical expertise
  • Written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process

Registration Renewal

Filing Method:

Online

Agency Fee:

$1,000 for accredited organizations or $1,500 for unaccredited organizations.

Due:

Biennially at least 30 days prior to the expiration date.

Required Attachments:
  • A current copy of the applicable accreditation certificate from the American Accreditation Healthcare Commission (URAC) if applicable
  • Any material changes to the information filed under your prior registration

Amendment
Material Change Amendment

Filing Method:

Online

Due:

Within 30 days after the change.

Law:

50 IL Admin Code 4530.60

Notes:

Any material changes in the information filed on the registration application must be reported.

Supplemental Reporting
External Review Report

Filing Method:

Online

Agency Fee:

$0

Due:

Annually by March 1.

Law:

50 IL Admin Code 4530.50

Notes:

Each independent review organization shall maintain written records in the aggregate, by state, and by health carrier on all requests for external review for which it conducted an external review during a calendar year and submit to the director in a report format.

Illinois Utilization Review Organization Registration

Type of Review:

Medical or Workers' Compensation Utilization Review

Agency:Illinois Department of Insurance
Law:

820 ILCS 305/8.7

Registered Agent (Special Agency) Required?Yes

Initial Registration

Filing Method:

Online

Agency Fee:

$1,500 for accredited organizations or $3,000 for unaccredited organizations.

Required Attachments:
  • Written policies and procedures for protecting confidential information according to applicable State and federal laws for each utilization review program
  • Biographical information for organization officers and directors

Registration Renewal

Filing Method:

Online

Agency Fee:

$1,500 for accredited organizations or $3,000 for unaccredited organizations.

Due:

Biennially

Required Attachments:
  • Written policies and procedures for protecting confidential information according to applicable State and federal laws for each utilization review program
  • Biographical information for organization officers and directors

Amendment
Material Change Amendment

Filing Method:

Online

Due:

Within 30 days after the change.

Law:

50 IL Admin Code 2905.40

Notes:

Any material changes in the information filed on the registration application must be reported.

Illinois Resources

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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