Illinois Workers’ Comp Treatment Denials: New Law HB 5228 Changes the Rules

Key Takeaways

• HB 5228 became effective on August 7, 2026.
• A physician-recommended treatment cannot receive an adverse utilization review determination from just any reviewer. The new law imposes specific professional qualifications.
• Treatment certifications now remain valid for a defined period, and surgery certifications include certain post-operative care when clinically indicated.
• The law establishes an appeals process for utilization review non-certifications.
• When an employer uses a medical examination to challenge the reasonableness and necessity of treatment instead of utilization review, new specialty and timing requirements apply.
• Failure to comply with examination requirements can create a rebuttable presumption involving additional compensation under the Workers’ Compensation Act.

If your doctor recommended treatment and workers’ compensation denied it, contact Strong Law Offices for a free consultation. We will review your denial and determine how the new law may affect your claim.

What Does HB 5228 Change for Illinois Workers’ Comp Treatment Denials?

HB 5228 changes important rules surrounding who can determine that treatment is not medically necessary and what must happen after treatment is approved or denied.

For injured workers, the practical effect is significant. An Illinois workers’ compensation treatment denial should now be examined not only for why treatment was denied but also for who made that decision and whether the required process was followed.

The law strengthens requirements in three areas that can directly affect access to medical care:

• Qualifications for professionals making adverse utilization review determinations
• Treatment certifications and appeals of non-certifications
• Certain medical examinations used instead of utilization review to challenge treatment

These changes give injured workers and their attorneys issues to examine when an insurance company refuses to authorize care.

A Denial Has to Come From a Qualified Medical Professional

Under the amended Section 8.7, only a licensed health care professional may determine that a medical service is not medically necessary.

If a physician recommended your treatment, an adverse determination must be made by a physician. The professional making the adverse determination must also meet qualifications relevant to the treatment being reviewed. Among other requirements, the reviewer must have current board certification in the appropriate specialty and experience treating patients with the condition at issue.

A reviewer also may not make an adverse determination on a service requested by a provider who is licensed in a profession different from the reviewer’s profession.

That means the identity and credentials of the person behind a utilization review denial in Illinois matter.

A denial is no longer something an injured worker should simply accept at face value. Ask who made it. Ask what their specialty is. Ask whether they actually meet the requirements of the amended law.

Approvals Now Have Staying Power

HB 5228 also gives treatment certifications a defined period of validity.

A utilization review certification remains valid for three months after the employee and health care provider receive it, or for the length of treatment determined by the employee’s provider, as provided by the Act.

For surgery, the certification also includes three months of post-operative care when clinically indicated.

This matters because an approval should allow treatment to move forward. An injured worker who finally obtains authorization should not immediately face another unnecessary fight over care covered by that certification.

The new law also establishes an appeals process for utilization review non-certifications. When the requested care was recommended by a physician, the appeal must include review by a physician who meets the law’s applicable requirements.

So if treatment is denied, the first decision does not necessarily end the issue.

The IME Route Now Comes With Important Requirements

HB 5228 also addresses situations where an employer asks a medical practitioner to examine the reasonableness and necessity of proposed or provided medical treatment instead of using utilization review.

This distinction matters. The new requirements do not apply to every independent medical examination for every purpose.

When an employer uses this type of examination to challenge treatment instead of utilization review, the amended Section 12 requires the medical practitioner to provide the examination and report to the employee or the employee’s representative and the treating health care professional within 90 days under the circumstances specified in the law.

The employer must exercise due diligence in requesting and collecting the relevant medical records. The practitioner performing the examination must also be board certified in the same specialty as the treating health care professional.

What Happens If Your Employer Misses the New Requirements?

The new requirements have teeth.

When the applicable requirements are not met, HB 5228 provides for a rebuttable presumption that the employer is responsible for additional compensation under Sections 16 and 19(l) of the Workers’ Compensation Act for failing to authorize or approve treatment and for failing to pay for it.

A rebuttable presumption does not mean penalties and fees are automatic in every case. The employer has an opportunity to rebut it.

But the change gives injured workers an important reason to document exactly what happened.

Dates matter. Reviewer qualifications matter. Delivery of the report matters.

When an insurance company or employer is using a medical examination to keep you from receiving treatment, compliance with the new requirements should be examined carefully.

How Is Strong Law Offices Putting HB 5228 to Work?

Knowing the law changed is not the same as using it.

When Strong Law Offices handles a denied-treatment dispute, we focus on the details that can determine whether the denial withstands scrutiny under the new rules.

We Audit the Denial

Who made the adverse determination? What is that person’s profession and board certification? Do they have experience treating the condition involved?

If the reviewer does not satisfy the requirements of Section 8.7, that may become an important issue in challenging the denial.

We Time the Examination

When the new Section 12 requirements apply, we track the timeline and determine whether the examination and report were provided as required.

A carrier should not be able to leave an injured worker waiting indefinitely while recommended medical care remains unresolved.

We Pursue Available Penalties and Fees

When an employer’s conduct triggers the new rebuttable presumption, we examine whether additional compensation under Sections 16 and 19(l) should be pursued.

The issue may be more than getting treatment approved. The way the employer handled the treatment request can matter too.

We Keep Your Doctor in the Loop

The amended law requires the examination report to be provided to the treating health care professional when the new provision applies.

We make sure that requirement is examined because your doctor needs to know why another practitioner disagrees with the recommended care and should have the opportunity to address that opinion.

We Review Existing Treatment Disputes

If your treatment was denied before HB 5228 became law but your workers’ compensation claim remains active, do not assume there is nothing more to examine.

Whether the new provisions affect a particular treatment dispute depends on the timing of the claim. We can review what happened, where the dispute stands now, and what options may remain.

What Should You Do If Workers’ Comp Is Denying Treatment Now?

If your doctor says you need surgery, therapy, injections, diagnostic testing, or another form of care and workers’ compensation refuses to authorize it, get the denial reviewed.

Keep the denial letter. Keep any utilization review documents. If you attended an examination, keep track of when it occurred and whether you or your doctor received a report. Most importantly, do not assume the insurance company followed the new law simply because it sent you a denial.

HB 5228 gives injured workers and their workers’ compensation attorneys new questions to ask about the people making medical-necessity decisions and the process employers use to dispute treatment.

Managing attorney Todd A. Strong is both a licensed attorney and a Certified Public Accountant. That combination brings a legal and financial perspective to workers’ compensation disputes where a carrier’s denial is really a cost decision dressed up as a medical one.

Contact Strong Law Offices today for a free consultation. No fee unless we recover for you. 309-393-2928.