HB3812 97TH GENERAL ASSEMBLY

LRB097 13098 RPM 57604 b

97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB3812

Introduced 10/5/2011, by Rep. Daniel J. Burke

SYNOPSIS AS INTRODUCED:

215 ILCS 5/368c

Amends the Illinois Insurance Code. Provides that prior to providing care to a person, a health care professional or health care provider shall verify whether that health care professional or health care provider is in the network of participating providers whose services are covered by the person's policy of accident and health insurance and shall notify the person of this information.

A BILL FOR

AN ACT concerning insurance.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by changing Section 368c as follows:

(215 ILCS 5/368c)

Sec. 368c. Remittance advice and procedures.

(a) A remittance advice shall be furnished to a health care professional or health care provider that identifies the disposition of each claim. The remittance advice shall identify the services billed; the patient responsibility, if any; the actual payment, if any, for the services billed; and the reason for any reduction to the amount for which the claim was submitted. For any reductions to the amount for which the claim was submitted, the remittance shall identify any withholds and the reason for any denial or reduction.

A remittance advice for capitation or prospective payment arrangements shall be furnished to a health care professional or health care provider pursuant to a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization in accordance with the terms of the contract.

(b) When health care services are provided by a non-participating health care professional or health care provider, an insurer, health maintenance organization, independent practice association, or physician hospital organization may pay for covered services either to a patient directly or to the non-participating health care professional or health care provider.

(c) When a person presents a benefits information card, a health care professional or health care provider shall make a good faith effort to inform the person if the health care professional or health care provider has a participation contract with the insurer, health maintenance organization, or other entity identified on the card.

(d) Notwithstanding any other provision of this Section, prior to providing care to a person, a health care professional or health care provider shall verify whether that health care professional or health care provider is in the network of participating providers whose services are covered by the person's policy of accident and health insurance and shall notify the person of this information.

(Source: P.A. 93-261, eff. 1-1-04.)