Sec. 40. Requirements for adverse determination.
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/il/chapter-215/act-200/40A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Sec. 40. Requirements for adverse determination. If a health insurance issuer or its contracted utilization review organization makes an adverse determination, the health insurance issuer or its contracted utilization review organization shall include the following in the notification to the enrollee, the enrollee's health care professional, and the enrollee's health care provider:
(1)the reasons for the adverse determination and related evidence-based criteria,
including a description of any missing or insufficient documentation;
(2)the right to appeal the adverse determination;
(3)instructions on how to file the appeal; and
(4)additional documentation necessary to support the appeal.