Utilization Review Organization Registration Guidelines
What are Health Care Utilization Review Organizations?
A Health Care Utilization Review Organization (URO) is an entity that has established one
or more utilization review programs, which evaluates the medical necessity,
appropriateness, and efficiency of the use of health care services, procedures,
and facilities. Not included in this definition are:
- persons providing utilization review program services only to the federal
government;
- self-insured health plans under the Federal Employee Retirement Income Security
Act of 1974 (ERISA). Note - Persons conducting a utilization review
program on behalf of these health plans must register; and
- hospitals and medical groups performing utilization review activities for
internal purposes. Note - hospitals or medical groups, conducting utilization
review for another person must register
When must Health Care Utilization Review Organizations Register?
Beginning July 1, 2000, all UROs must register
with the Director of Insurance. Registration of Illinois UROs is effective for
a period of two years and must be renewed
biennial. Each URO registration must contain a completed Application
for Registration of a Utilization Review Organization (Section 5420 Exhibit
D) and Utilization Review Organization Officers
and Directors Biographical Affidavit (Section 5420 Exhibit E).
Beginning July 25, 2005, Illinois registered Health Care Utilization review Organizations which meet or exceed URAC's Health Utilization Management Standards, may also conduct a utilization review program for Worker Compensation Services. All such entities must indicate their intent to do so within Section 2 of their Application for Registration of a Utilization Review Organization (Section 5420 Exhibit D).
What is the registration fee for an Illinois Utilization Review Organization?
A registration fee of $3,000 must be submitted with each application
or renewal, unless the URO holds a current accreditation with one or more of
the following:
- American Accreditation Healthcare Commission (URAC)
- National Committee for Quality Assurance (NCQA)
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
in which case the registration and renewal fee will be $1,500. All checks
or money orders must be made payable to the Director of Insurance, State of
Illinois.
Mail Completed Applications to:
Illinois Department of Insurance
Utilization Review /Managed Care Compliance Unit
320 West Washington Street
Springfield, Il 62767-0001
ANY MATERIAL CHANGES IN YOUR URO APPLICATION MUST BE FILED WITH THE DIRECTOR
WITHIN 30 DAYS OF THE CHANGE.
For questions or more information, please contact:
Kelly Smith
Insurance Analyst
Illinois Department of Insurance
Utilization Review / Managed Care Compliance Unit
(217) 558-2309
(217) 557-8478 fax
kelly.smith@Illinois.gov