Prior Authorization Reform Act (HB0711) Summary

• Establishes transparency requirements for health insurance issuers to maintain and publish complete lists of services requiring prior authorization, including written clinical review criteria based on nationally recognized standards, with annual updates and approval/denial statistics.

• Requires non-urgent prior authorization decisions within 5 calendar days and urgent care decisions within 48 hours after obtaining necessary information, with automatic authorization if insurers fail to meet deadlines.

• Mandates that adverse determinations be made by physicians when requested by physicians, and that reviewing physicians have current licenses and experience with the condition being treated; limits revocation of previously approved authorizations.

• Sets prior authorization approval validity periods of 6 months for standard services and 12 months for chronic or long-term conditions, with continuity of care protections for enrollees switching plans (90-day honor period for prior authorizations from previous insurers).

• Applies to health insurance coverage in Illinois with exceptions for self-insured plans, workers' compensation, and certain state/local government plans; enforcement by Department of Insurance with authority to impose fines up to $250,000 for violations; effective January 1, 2022.