Governor J.B. Pritzker signed Illinois House Bill 5228 into law, creating new requirements for utilization review (UR) and independent medical evaluations (IME).

New UR requirements include:

• Adverse UR determinations and appeals are subject to new reviewer qualification standards
• UR certifications remain valid for three months after receipt by the employee and provider, or for the length of treatment determined by the treating provider
• Surgical approvals must include three months of post-operative care, or the length of treatment determined by the treating provider
• Confidentiality requirements for patient information obtained through the UR process

New IME requirements include:

• IME physicians used in place of UR must be board certified in the same specialty as the treating provider
• IME reports must be provided to the employee, the employee's representative, and the treating provider within 90 days after the employer receives records related to the disputed treatment
• Employers and their representatives must exercise due diligence in obtaining records needed to complete the review
• Noncompliance may create rebuttable presumptions supporting delay penalties and attorney fee awards.

Employers, payers, and utilization review organizations must comply with these new requirements. These changes create compliance and operational considerations for those involved in utilization review and medical necessity determinations.