Consumers’ Rights for Independent External Review of Health Insurance Claims

Appealing Health Carrier Decisions

Helping your patients/clients appeal a denied service or treatment


The Illinois Department of Insurance is reminding consumers, health care providers, and patient advocates about consumers’ rights for an independent external review when their health insurance carrier denies a claim or request based upon medical necessity (including health care setting, level of care or effectiveness), experimental/investigational, a pre-existing condition, or rescission of the policy. 

This law applies to pre-service, concurrent stay and post service adverse determinations. If the situation is urgent (the time frame for a standard appeal or review could seriously jeopardize the life or health of the covered person), then an expedited internal appeal and/or expedited independent external review may be requested.  For all other requests, the internal appeals process through insurance carrier must be exhausted prior to requesting an external independent review. 

Requests for independent external reviews are filed with the Department of Insurance by fax, on-line or by U.S. mail.  An independent review organization (“IRO”) registered with the Department is randomly assigned to the review, which must be conducted by a clinical reviewer who is a physician or other appropriate health care provider with: (1) expertise in the treatment of the covered person’s medical condition that is the subject of the review, (2) knowledge about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar condition of the patient, (3) holds a non-restricted license in the United States, and for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and (4) has no history of disciplinary actions. For standard reviews, the consumer and/or their authorized representative are notified by the Department of the IRO assigned to the review and are invited to submit any documentation applicable to the request.  The carrier is required to send all medical records related to the request to the assigned IRO.  Standard reviews are generally finalized within 4-6 weeks and the decision is final, but may be appealed through the court system.

Fully insured Illinois policies are subject to the Illinois law and it generally applies to most major medical polices, including those purchased under the Affordable Care Act (ACA).  However, the Department’s Office of Consumer Health Insurance assists consumers by trying to ascertain the type of plan involved, applicable appeal procedures and appropriate avenues for the appeal.

For more information regarding independent external reviews in Illinois, contact the Office of Consumer Health Insurance at (877) 850-4740 or visit the Department’s website at  

CAPriCORN to Participate in Aspirin Study


Contact:  Heather M. Tarczan

Chicago Area Patient Centered Outcomes Research Network (CAPriCORN) to Help Determine Best Aspirin Dose to Protect Patients with Heart Disease

First PCORnet Demonstration Study Could Help Guide Treatment Options for Millions

May 18, 2015  – Chicago Area Patient Centered Outcomes Research Network (CAPriCORN) will play a key role in a new $14 million research study announced today by the Patient-Centered Outcomes Research Institute (PCORI) to determine the best daily dose of aspirin to use in preventing heart attacks and strokes among people living with heart disease.  CAPriCORN is one of six health system-based data networks that will conduct the three-year clinical trial funded by


Please open attachment below to read more....



Download this file (AdaptableTrial_May182015.pdf)AdaptableTrial_May182015.pdf[ ]414 kB

Vertiport Grand Opening 4.30.15



Next generation of urban air transportation takes off with debut of
Vertiport Chicago

Vertiport Chicago is largest facility of its kind in North America;
New downtown helicopter access serves as key regional economic driver;
Enhanced emergency response for city and hospitals


Chicago (April 30, 2015) – The future of urban air transportation is taking off in Chicago with the debut of Vertiport Chicago, the largest vertical aircraft takeoff and landing facility of its kind in North America, providing a vital downtown transportation link for businesses, enhancing emergency medical response for patients, and driving regional commerce and tourism. Located in the Illinois Medical District, Vertiport Chicago is 10-acre $11 million privately funded facility serving both helicopters and the next-generation tiltrotor aircraft. Vertiport Chicago brings private helicopter access to downtown for the first time since the closure of Meigs Field in 2003.


Please click here to read full press release


IMD&U: Learn Our Story. Share Our Vision.

As an IMD partner or key constituent, you aren’t just part of the Illinois Medical District story, you—and those you serve—are the heart of it. Throughout 2017 we will share monthly updates on all that is taking place in the IMD and encourage U to be part of our story by emailing IMD& with ideas and topics of interest.

Join the conversation on Twitter and Facebook with the hashtag #IMDandU.


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