SB3822 - Prior Authorization Reform Act

• Establishes comprehensive requirements for prior authorization programs including disclosure of requirements, clinical review criteria based on nationally recognized standards, and monthly publication of approval/denial statistics on websites.

• Mandates utilization review programs make prior authorization decisions within 48 hours for nonurgent care, 24 hours for urgent care, and 60 minutes for post-stabilization services; services are automatically deemed authorized if deadlines are missed.

• Prohibits prior authorization for emergency health care services and pre-hospital transportation; requires 24-hour notification grace period after emergency admission and presumes medical necessity if certified by provider within 72 hours.

• Requires adverse determinations be made by physicians in the same specialty as treating physicians, with appeal reviews conducted by independent physicians not employed by the plan; requires pre-denial consultation opportunity with treating providers.

• Establishes 15-month validity period for prior authorizations (or full treatment length for chronic conditions); prohibits retroactive denials of previously authorized services and requires continuity of care when enrollees change plans.

• Authorizes Department of Insurance to impose fines up to $250,000 for violations; applies to health insurers and managed care organizations providing coverage in Illinois, effective January 1, 2021.