Illinois Prior Authorization Law

Overview

Illinois HB 2847 (effective 2024) sets strict timelines for prior authorization decisions. Insurers must respond to standard requests within 5 business days and urgent requests within 48 hours. All denials require clinical rationale grounded in medical policy. Prior authorization delays are subject to penalties and external review.

Key Requirements

1. Insurers must acknowledge PA requests within 24 hours of receipt and provide decision timeline.
2. Standard PA decisions within 5 business days; urgent decisions within 48 hours.
3. All PA denials must include specific clinical rationale tied to the patient's diagnosis and clinical presentation.
4. Providers may request expedited review if they believe the standard timeline is medically inappropriate.
5. Insurers must provide clear appeal procedures and external review access with each denial.

Penalties and Enforcement

Insurers who fail to meet PA timelines or deny without clinical rationale face fines from the Illinois Department of Insurance. Providers may bill at usual and customary rates if the insurer misses the decision deadline. Patients may seek external review and damages. Repeat violations trigger license sanctions and increased fines.

Appeals and Exceptions

Urgent PA requests must be expedited based on clinical necessity. Denials may be appealed to the insurer's medical director within 10 business days. Providers and patients have the right to independent external review if internal appeals are unsuccessful. Certain denial codes trigger automatic expedited review.

Interaction with Federal Law

Illinois PA timelines exceed federal requirements in some cases. The 48-hour urgent standard aligns with federal timelines. Illinois requires clinical rationale documentation; federal law does not mandate this level of detail. Providers and patients benefit from the more protective Illinois standard. NSA rules complement PA protections.

Common Questions