Section 2018.10  Purpose and Applicability

 

a)         This Part provides the contents of the electronic form that an insurer imposing prior authorization requirements on prescription benefits is required to utilize and accept for any health insurance coverage beginning July 1, 2021 under Section 364.3 of the Code. This form is intended to simplify exchanges of information between prescribing providers and insurers for prior authorization requests.

 

b)         This Part does not apply to any health insurance coverage that does not require prior authorization for any prescription benefits.

 

Section 2018.20  Definitions

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Department" means the Illinois Department of Insurance.

 

"Insurer" means a "health insurance issuer" as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act [215 ILCS 97].

 

"Health insurance coverage" has the meaning ascribed in Section 5 of the Illinois Health Insurance Portability and Accountability Act.

 

"Prescribing provider" has the meaning ascribed in Section 364.3(a) of the Code.

 

"Prescription" has the meaning ascribed in Section 3(e) of the Pharmacy Practice Act [225 ILCS 85].

 

Section 2018.30  Uniform Electronic Prior Authorization Form for Prescription Benefits

 

On and after July 1, 2021, an insurer that imposes prior authorization requirements on prescription benefits in any health insurance coverage shall utilize and accept the uniform electronic prior authorization form containing the elements listed in this Section. An insurer shall require any person conducting prior authorization of prescription drug benefits on its behalf to utilize and accept this form. If any prescribing provider fails to use this form to request prior authorization of prescription benefits, the insurer will not be subject to the requirements of Section 364.3 of the Code for that request. Only the version of the PDF that is posted on the Department's website shall satisfy the requirements of this Part. The posted PDF shall consist of the following elements:

 

a)         The title, which will be: "Illinois Uniform Electronic Prior Authorization Form for Prescription Benefits".

 

b)         An explanatory introduction, which will contain the following text:

 

This form is made available for use by prescribing providers to initiate a prior authorization request with a commercial health insurance issuer ("insurer") regulated by the Illinois Department of Insurance.

 

"Prior authorization request" means a request for pre-approval from an insurer for a specified prescription or quantity of a prescription before the prescription is dispensed.

 

"Prescribing provider" has the meaning ascribed in Section 364.3 of the Illinois Insurance Code [215 ILCS 5].

 

"Prescription" has the meaning ascribed in Section 3(e) of the Pharmacy Practice Act [225 ILCS 85].

 

If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of this form, an insurer fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours (if the patient has urgent medication needs), or within 72 hours (if the patient has regular medication needs), then the prior authorization request shall be deemed to have been granted. [215 ILCS 5/364.3(f)] The prescribing provider should only provide its direct contact number and initials if requesting an Expedited Review Request.

 

The provisions of this form do not serve as a replacement for the step therapy and formulary exception requests that may require additional information and forms as provided in Sections 25(a)(3) and 45.1 of the Managed Care Reform and Patient Rights Act [215 ILCS 134]. Nothing in this form shall be construed to alter or nullify any provisions of federal or Illinois law that impose obligations on insurers, prescribing providers, or patients related to responsiveness, adjudication and/or appeals.

 

Prior authorization alone is not a guarantee of benefits or payment. Actual availability of benefits is always subject to other requirements of the health plan, such as limitations and exclusions, payment of premium, and eligibility at the time services are provided. The applicable terms of a patient's plan control the benefits that are available. At the time the claims are submitted, they will be reviewed in accordance with the terms of the plan.

 

Please refer to the plan's website for additional information that may be necessary for review.  Please note that sending this form with insufficient clinical information may result in an extended review period or adverse determination.  Insurers may require additional information based on the type of prescription drug being requested that may require follow-up inquiries with the provider.

 

PRESCRIBING PROVIDERS:  PLEASE SUBMIT THIS FORM TO THE PATIENT'S HEALTH PLAN ONLY. Please do not send forms to the Department of Insurance.

 

c)         A section to indicate whether the prescribing provider is making a Standard Review Request or an Expedited Review Request. For an Expedited Review Request, the following certification shall appear: "I hereby certify that a standard review period may seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function." The certification shall have spaces for the prescribing provider to add initials and a direct telephone number to contact the prescribing provider.

 

d)         A section entitled "Reason for Request", which will contain options for an Initial Authorization Request, a Renewal Request, and a Dispense As Written (DAW). The section will also have a note that states:  "Note:  This form does not apply to requests for medical exceptions under Sections 25(a)(3) or 45.1 of the Managed Care Reform and Patient Rights Act [215 ILCS 134]. Please contact the patient's health plan to obtain the appropriate forms."

 

e)         A section entitled "Patient Demographics", which will request the following information:

 

1)         Whether the patient is hospitalized;

 

2)         Patient Name;

 

3)         Patient Date of Birth;

 

4)         Patient Health Plan ID;

 

5)         Patient Health Plan Group Number (if applicable);

 

6)         Patient Address;

 

7)         Patient Phone; and

 

8)         Patient Sex.

 

f)         A section entitled "Prescribing Provider Information", which will request the following information:

 

1)         Prescribing Provider Name;

 

2)         NPI;

 

3)         Specialty;

 

4)         DEA Number (required for controlled substance requests only);

 

5)         Contact Name;

 

6)         Contact Phone;

 

7)         Contact Fax;

 

8)         Contact Address;

 

9)         Contact Email Address (optional); and

 

10)        Health Plan Provider ID (if accessible).

 

g)         A section entitled "Pharmacy Information", which will request the following information:

 

1)         Pharmacy Name; and

 

2)         Pharmacy Phone.

 

h)         A section entitled "Requested Prescription Drug Information", which will request the following information:

 

1)         Drug Name;

 

2)         Strength;

 

3)         Dosing Schedule;

 

4)         Duration;

 

5)         Diagnosis (specific with ICD#);

 

6)         Place of infusion/injection (if applicable);

 

7)         Facility Provider ID/NPI;

 

8)         Ingredients within drug; and

 

9)         Whether the patient has already started the medication and, if so, when.

 

i)          A section entitled "Rationale for Prior Authorization", which will request information such as history of present illness, past medical history, current medications, etc. The section will indicate that the prescribing provider may also attach chart notes to support the request if the provider believes the notes will assist in the review process.

 

j)          A section entitled "Failed/Contraindicated Therapies", if applicable in the provider's opinion, which will request the following information:

 

1)         Drug name;

 

2)         Strength;

 

3)         Dosing Schedule;

 

4)         Duration; and

 

5)         Adverse Event/Specific Failure.

 

k)         A section entitled "Other Pertinent Information", which will contain the following text: "Optional:  To be filled out if other information in the prescribing provider's professional opinion is necessary, such as relevant diagnostic labs, measures, response to treatment, etc." The section will contain blank space for the prescribing provider to provide this information.  

 

l)          A section entitled "Insurer Contact and Submission Information", where an insurer must provide its unique contact information, including any electronic portal it may use for submission of the form and any links to the insurer's prior authorization form and guidelines. The insertion of this information is the only alteration that an insurer may make to the PDF posted on the Department's website before furnishing it to a prescribing provider.

 

m)        A section entitled "Representation", which will contain the following text:

"I represent to the best of my knowledge and belief that the information provided is true, complete, and fully disclosed. A person may be committing insurance fraud if false or deceptive information with the intent to defraud is provided." The section will include spaces for the prescribing provider to insert the following:

 

1)         Prescribing Provider Name;

 

2)         Signature; and

 

3)         Date.

 

n)         A section entitled "For Health Plan Use Only", which will request the following information from the insurer in response to a submitted form:

 

1)         Request date;

 

2)         Limitation of Benefits (LOB);

 

3)         Approved;

 

4)         Denied;

 

5)         Approved by (name and credentials);

 

6)         Denied by (name and credentials);

 

7)         Reviewed by (name and credentials);

 

8)         Effective date;

 

9)         Reason for denial; and

 

10)        Additional comment, if any.

 

o)         The month and year of the version of the form.