215 ILCS 200/35: Personnel qualified to make adverse determinations of a prior authorization request.

A health insurance issuer or its contracted utilization review organization must ensure that all adverse determinations are made by a physician when the request is by a physician or a representative of a physician. The physician must:

(1) possess a current and valid nonrestricted license in any United States jurisdiction; and

(2) have experience treating and managing patients with the medical condition or disease for which the health care service is being requested.

Notwithstanding the foregoing, a licensed health care professional who satisfies the requirements of this Section may make an adverse determination of a prior authorization request submitted by a health care professional licensed in the same profession.