Catalog

Illinois HB 2472 (P.A. 103-0656; Managed Care Reform and Patient Rights Act, 215 ILCS 134)

Illinois Department of Insurance · pack 0.2.0 · verified against the official source as of 2026-10-03. Open it in the explorer.

Binding law — in force

Algorithmic review must use physician-set criteria, verified by board-certified physicians before changes and after errors (Illinois HB 2472)

From 2025-01-01, utilization review programs that use algorithmic automated processes to decide whether to render adverse determinations based on medical necessity must use objective, evidence-based criteria compliant with URAC or NCQA accreditation requirements and prove compliance with each registration (215 ILCS 134/85(b-10), (a)); the registration must attach policies and procedures (1) ensuring that licensed physicians with relevant board certifications establish all criteria the process uses and (2) for a program integrity system that, before new or revised criteria are used and when implementation errors are found, requires such physicians to verify that the process and its corrections yield results consistent with the criteria for their certified field. A plan or program using an automated process must have that accreditation and those policies (45(i)). Detect the absence of physician criteria sign-off and pre-release integrity verification.

il-hb2472.automated-process-criteria-and-integrity · 215 ILCS 134/85(b-10) · official source · jurisdictions: US-IL

The guard to add, and how far to trust this rule

Binding law — in force

Only a clinical peer makes adverse determinations; an algorithmic automated process may only certify or refer (Illinois HB 2472)

From 2025-01-01, even if a health care plan or other utilization review program uses an algorithmic automated process in utilization review for medical necessity, it must ensure that only a clinical peer (a health care professional in the same profession and the same or similar specialty as the provider who typically manages the condition) makes any adverse determination based on medical necessity, and that only a clinical peer reviews an appeal (215 ILCS 134/45(i)). Only a clinical peer may make adverse medical-necessity determinations; a health care professional or an accredited algorithmic automated process may certify medical necessity, and the process may refer a case to a clinical peer for a potential adverse determination (85(e)(2)). Detect automated output that sets a denial without a clinical peer, and prompts or schemas that ask the model to deny.

il-hb2472.clinical-peer-adverse-determination · 215 ILCS 134/45(i) and source note · official source · jurisdictions: US-IL

The guard to add, and how far to trust this rule