State guide
Illinois
Pick the kind of plan you have to see who to call first. Illinois can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
-
Your employer pays claims itself
Illinois usually cannot help with these plans. Call the Employee Benefits Security Administration.
-
Insurance you buy, or an employer plan bought from an insurer
Call Illinois Department of Insurance (Office of Consumer Health Insurance). See the at-a-glance box.
-
Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Illinois.
-
Medicare
Senior Health Insurance Program (SHIP), Illinois Department on Aging gives free counseling. Or call 1-800-MEDICARE.
The short version for Illinois
Illinois runs external review itself: the Illinois Department of Insurance takes your request, costs nothing, and assigns an independent reviewer, and in 2024 about 46 percent of the reviews that were eligible were fully overturned in the consumer's favor. Two free state helpers handle denials: the Department of Insurance's Office of Consumer Health Insurance and the Attorney General's Health Care Bureau, which contacts the insurer on your behalf. Since January 1, 2026, state-regulated plans may no longer impose step therapy (making you try cheaper drugs first).
At a glance: independent review for plans Illinois regulates
- Main regulator
- Illinois Department of Insurance (Office of Consumer Health Insurance) · 877-527-9431 (Office of Consumer Health Insurance); external review staff 877-850-4740
- Independent review
- A state process (External Review (independent medical review by an Independent Review Organization))
- Deadline to request it
- 4 months after you receive the insurer's final denial letter saying your internal appeals are used up. For urgent care you may file immediately after any denial.
- Cost
- None. The Department states there is no cost to the consumer.
- Decision time
- Generally within 45 days (the Department's request form refers to a standard external review taking 21 to 45 days); fast track: 72 hours for most expedited reviews; up to 7 calendar days when the denial is for experimental or investigational treatment (per the Department's 2015 annual report)
Who regulates health plans
The Illinois Department of Insurance does not give an insurance-card tip. It says plans it may have to refer elsewhere include self-insured employer, union, church or non-federal governmental plans (check your benefit booklet for the appeal process), group plans issued in another state, Medicare, Medicaid, federal employee, Tricare and military coverage, and limited coverage such as cancer-only, accident-only, dental, vision, disability income, hospital indemnity or long-term care policies.
- Illinois Department of Insurance (Office of Consumer Health Insurance)
Fully insured health plans issued in Illinois (individual and employer group policies bought from an insurance company or health maintenance organization). It does not review self-insured employer, union, church or non-federal government plans (where the employer pays claims itself), group plans issued in another state, Medicare, Medicaid, the Federal Employees Health Benefits Program, or Tricare.
Phone: 877-527-9431 (Office of Consumer Health Insurance); external review staff 877-850-4740. File a complaint online
- U.S. Department of Labor, Employee Benefits Security Administration
Self-insured employer plans offered by private-sector employers and unions, which the Illinois Department of Insurance does not oversee.
Phone: 866-444-3272. File a complaint online
Independent (external) review
- Process
- A state process. Run by Illinois Department of Insurance, which randomly assigns each case to an approved Independent Review Organization.
- Where you file
- regulator
- How
- Send the signed Request for External Review form, a copy of your insurance card and the insurer's final denial letter to the Department by its online Message Center, by email to DOI.externalreview@illinois.gov, by fax to (217) 557-8495, or by mail. If your care is urgent or the treatment is called experimental, your doctor must also complete a Physician Certification form. Questions: 877-850-4740.
- Which denials qualify
- Denials that involve medical judgment (medical necessity, appropriateness, effectiveness, level of care, health care setting, length of treatment), experimental or investigational treatment, pre-existing condition denials, and rescission (cancellation) of coverage for a reason other than unpaid premiums. Denials because a service is a plan exclusion are generally not eligible, and the Department refers those to its complaint process.
- Appeal to the plan first?
- Yes, you must finish the insurer's internal appeal and have its final denial. For urgent situations you can file for expedited external review immediately after any denial; the Department says internal appeal and external review rights are used up at the same time in expedited cases. Requesting an expedited review waives any remaining appeal steps, and you cannot add information afterward.
- Published results
- In 2024 Illinois received 4,468 external review requests; 1,351 were eligible, and of those 627 denials were overturned, 12 were partly overturned and 712 were upheld (about 46 percent fully overturned). The other 3,117 requests were ineligible, often because internal appeals were not finished first. Source
Free help in Illinois
- Illinois Department of Insurance, Office of Consumer Health Insurance
State staff explain your policy and rights and guide you through internal appeals, complaints and external review for state-regulated individual and employer plans; the federal consumer assistance directory lists this department as the state's help resource.
Phone: 877-527-9431
- Illinois Attorney General, Health Care Bureau
Mediators contact your insurer or provider for you on coverage denials, medical-necessity denials, partial payments and mental health or substance use claim denials, and help with the appeals and independent review process.
Phone: 1-877-305-5145
- Illinois Legal Aid Online
Free plain-language guides on how to appeal Medicaid decisions in Illinois, with links to local legal aid offices for people with low income.
Medicare and Medicaid in Illinois
- Medicare counseling
- Senior Health Insurance Program (SHIP), Illinois Department on Aging · 1-800-252-8966 (711 for relay service) . Free help with Medicare appeals.
- Medicaid agency
- Illinois Department of Healthcare and Family Services (Medicaid, including managed care health plans)
- Fair hearing deadline
- 120 calendar days from the date on your health plan's Notice of Appeal Resolution. Your notice states the deadline that applies to you.
- Good to know
- If you are in a Medicaid managed care plan, appeal to the plan first, within 60 calendar days of its Notice of Adverse Benefit Determination. To keep services going during the state fair hearing, you must ask for the hearing within 10 calendar days of the plan's appeal resolution notice, and you may owe for services if you lose. Medical services and items hearings go to the Healthcare and Family Services Bureau of Administrative Hearings (1-855-418-4421); mental health, substance use and certain waiver services go to the Department of Human Services Bureau of Hearings (800-435-0774).
State laws that can help
-
Step therapy. Beginning January 1, 2026, plans and utilization review programs regulated by Illinois may not impose step therapy requirements (making you try other drugs first); the ban does not apply to Medicaid step therapy for drugs not on the state's Preferred Drug List.
-
External review. You can ask the Department of Insurance for an independent external review of medical judgment, experimental treatment, pre-existing condition and rescission denials, and urgent requests can be filed orally or in writing right after a denial.
-
Denial notice. When an insurer denies a service, its notice must tell you in writing about your right to independent external review and include the Department of Insurance's Request for External Review form.
Sources and what we could not confirm
- Centers for Medicare & Medicaid Services: State External Appeals Review Processes
- Illinois Department of Insurance: How to File an External Review
- Illinois Department of Insurance: Request for External Review form (revised 6/2026)
- Illinois Department of Insurance: How to File a Complaint
- Illinois Department of Insurance: Office of Consumer Health Insurance 2024 Annual Report
- Illinois Department of Insurance: 2015 Annual Report (external review timeframes)
- Illinois Department of Insurance: Prescription Drug Coverage and PBM Reform
- Centers for Medicare & Medicaid Services: Illinois Consumer Assistance
- Illinois Department on Aging: Medicare Choices Guide for 2026 (phone numbers)
- Illinois Department on Aging: Senior Health Insurance Program
- Illinois Attorney General: Health Care
- Illinois Department of Healthcare and Family Services: How Illinois Medicaid managed care enrollees can file a grievance or appeal
- Illinois Legal Aid Online: Appealing a Medicaid decision
- Illinois Compiled Statutes 215 ILCS 134/87
- Illinois Compiled Statutes 215 ILCS 180/20
- Illinois Compiled Statutes 215 ILCS 180/40
Not confirmed (9)
- The state regulators. pages disagree: the Illinois Department on Aging guide and the department's brochure print 877-527-9431 for the Office of Consumer Health Insurance, while the federal consumer assistance page prints 866-445-4364 for the department's Consumer Services Section. Both are probably live; 877-527-9431 is used.
- How long a standard independent review takes. the Department's request form says a standard external review takes 21 to 45 days; the 45-day outer limit and 'generally 28 days' wording come from the 2015 annual report. No current official page states the standard time in one sentence.
- How long a fast independent review takes. 72 hours and 7 days come from the 2015 annual report; the current external review page and form do not restate them.
- The independent review request form. the 2026 form was read through a search extract, not opened in full; the online filing link on the Department's page (Message Center) was not tested.
- A searchable list of past decisions. no searchable database of past decisions was found.
- Not confirmed. regulators[0].url / medicaid — the Department of Insurance home page URL and the Healthcare and Family Services hearing contact numbers were taken from search extracts and the HFS PDF, not loaded as live pages.
- Not confirmed. stateLaws (prior-authorization, mental-health-parity, gold-card, ai-in-utilization-review, surprise-billing) — the Department names a Prior Authorization Reform Act of 2022 and a 2026 ban on prior authorization for certain behavioral health levels of care, but the statute text was not read, so none is listed. No Illinois law on these topics was confirmed.
- Not confirmed. stateLaws (step-therapy) — only subsection (f) of 215 ILCS 134/87 was read from a search extract; the rest of the section, including medical necessity criteria rules effective January 1, 2026, was not read.
- Free consumer help programs. Illinois Legal Aid Online has no phone listed in the pages loaded, so the phone is null.