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: | |
| Foreign Qualification is Prerequisite: | Not Set |
| Exam Required? | Not Set |
| Registered Agent (Special Agency) Required? | Yes |
Initial Registration
| Filing Method: | |
| Agency Fee: | $1,000 for accredited organizations or $1,500 for unaccredited organizations. |
| Required Attachments: |
|
Registration Renewal
| Filing Method: | |
| 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: |
|
Amendment
Material Change Amendment
| Filing Method: | |
| Due: | Within 30 days after the change. |
| Law: | |
| Notes: | Any material changes in the information filed on the registration application must be reported. |
Supplemental Reporting
External Review Report
| Filing Method: | |
| Agency Fee: | $0 |
| Due: | Annually by March 1. |
| Law: | |
| 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
Initial Registration
| Filing Method: | |
| Agency Fee: | $1,500 for accredited organizations or $3,000 for unaccredited organizations. |
| Required Attachments: |
|
Registration Renewal
| Filing Method: | |
| Agency Fee: | $1,500 for accredited organizations or $3,000 for unaccredited organizations. |
| Due: | Biennially |
| Required Attachments: |
|
Amendment
Material Change Amendment
| Filing Method: | |
| Due: | Within 30 days after the change. |
| Law: | |
| 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.
