IL HB2472

Accident and health insurers must send explanation of benefits statements in clear, understandable format showing total amount submitted, reductions for copayments/coinsurance/deductibles, other policy limitations, total paid, and total unpaid amounts.

Utilization review programs conducting adverse medical necessity determinations must use objective, evidence-based criteria and ensure only licensed clinical peers (not automated processes alone) make adverse determinations, with accreditation required from approved organizations.

Health insurance issuers cannot impose penalties exceeding the lesser of actual service cost or $1,000 per occurrence for failure to obtain prior authorization, and cannot require both enrollees and providers to obtain authorization for the same service.

Section 143.31 of the Illinois Insurance Code (uniform medical claim and billing forms) now applies to fraternal benefit societies, dental service plan corporations, health maintenance organizations, limited health service organizations, and voluntary health services plans.

"Adverse determination" definition expanded to include unilateral service replacements without agreement, conditioning approval on first trying alternatives, and determinations based on any health information used to deny, reduce, replace, condition, or terminate benefits.