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| Public Act 098-0154 | ||||
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by | ||||
changing Section 356z.3a as follows: | ||||
(215 ILCS 5/356z.3a) | ||||
Sec. 356z.3a. Nonparticipating facility-based physicians | ||||
and providers. | ||||
(a) For purposes of this Section, "facility-based | ||||
provider" means a physician or other provider who provide | ||||
radiology, anesthesiology, pathology, neonatology, or | ||||
emergency department services to insureds, beneficiaries, or | ||||
enrollees in a participating hospital or participating | ||||
ambulatory surgical treatment center. | ||||
(b) When a beneficiary, insured, or enrollee utilizes a | ||||
participating network hospital or a participating network | ||||
ambulatory surgery center and, due to any reason, in network | ||||
services for radiology, anesthesiology, pathology, emergency | ||||
physician, or neonatology are unavailable and are provided by a | ||||
nonparticipating facility-based physician or provider, the | ||||
insurer or health plan shall ensure that the beneficiary, | ||||
insured, or enrollee shall incur no greater out-of-pocket costs | ||||
than the beneficiary, insured, or enrollee would have incurred | ||||
with a participating physician or provider for covered | ||
services. | ||
(c) If a beneficiary, insured, or enrollee agrees in | ||
writing, notwithstanding any other provision of this Code, any | ||
benefits a beneficiary, insured, or enrollee receives for | ||
services under the situation in subsection (b) are assigned to | ||
the nonparticipating facility-based providers. The insurer or | ||
health plan shall provide the nonparticipating provider with a | ||
written explanation of benefits that specifies the proposed | ||
reimbursement and the applicable deductible, copayment or | ||
coinsurance amounts owed by the insured, beneficiary or | ||
enrollee. The insurer or health plan shall pay any | ||
reimbursement directly to the nonparticipating facility-based | ||
provider. The nonparticipating facility-based physician or | ||
provider shall not bill the beneficiary, insured, or enrollee, | ||
except for applicable deductible, copayment, or coinsurance | ||
amounts that would apply if the beneficiary, insured, or | ||
enrollee utilized a participating physician or provider for | ||
covered services. If a beneficiary, insured, or enrollee | ||
specifically rejects assignment under this Section in writing | ||
to the nonparticipating facility-based provider, then the | ||
nonparticipating facility-based provider may bill the | ||
beneficiary, insured, or enrollee for the services rendered. | ||
(d) For bills assigned under subsection (c), the | ||
nonparticipating facility-based provider may bill the insurer | ||
or health plan for the services rendered, and the insurer or | ||
health plan may pay the billed amount or attempt to negotiate | ||
reimbursement with the nonparticipating facility-based | ||
provider. If attempts to negotiate reimbursement for services | ||
provided by a nonparticipating facility-based provider do not | ||
result in a resolution of the payment dispute within 30 days | ||
after receipt of written explanation of benefits by the insurer | ||
or health plan, then an insurer or health plan or | ||
nonparticipating facility-based physician or provider may | ||
initiate binding arbitration to determine payment for services | ||
provided on a per bill basis. The party requesting arbitration | ||
shall notify the other party arbitration has been initiated and | ||
state its final offer before arbitration. In response to this | ||
notice, the nonrequesting party shall inform the requesting | ||
party of its final offer before the arbitration occurs. | ||
Arbitration shall be initiated by filing a request with the | ||
Department of Insurance. | ||
(e) The Department of Insurance shall publish a list of | ||
approved arbitrators or entities that shall provide binding | ||
arbitration. These arbitrators shall be American Arbitration | ||
Association or American Health Lawyers Association trained | ||
arbitrators. Both parties must agree on an arbitrator from the | ||
Department of Insurance's list of arbitrators. If no agreement | ||
can be reached, then a list of 5 arbitrators shall be provided | ||
by the Department of Insurance. From the list of 5 arbitrators, | ||
the insurer can veto 2 arbitrators and the provider can veto 2 | ||
arbitrators. The remaining arbitrator shall be the chosen | ||
arbitrator. This arbitration shall consist of a review of the | ||
written submissions by both parties. Binding arbitration shall | ||
provide for a written decision within 45 days after the request | ||
is filed with the Department of Insurance. Both parties shall | ||
be bound by the arbitrator's decision. The arbitrator's | ||
expenses and fees, together with other expenses, not including | ||
attorney's fees, incurred in the conduct of the arbitration, | ||
shall be paid as provided in the decision. | ||
(f) This Section 356z.3a does not apply to a beneficiary, | ||
insured, or enrollee who willfully chooses to access a | ||
nonparticipating facility-based physician or provider for | ||
health care services available through the insurer's or plan's | ||
network of participating physicians and providers. In these | ||
circumstances, the contractual requirements for | ||
nonparticipating facility-based provider reimbursements will | ||
apply. | ||
(g) Section 368a of this Act shall not apply during the | ||
pendency of a decision under subsection (d) any interest | ||
required to be paid a provider under Section 368a shall not | ||
accrue until after 30 days of an arbitrator's decision as | ||
provided in subsection (d), but in no circumstances longer than | ||
150 days from date the nonparticipating facility-based | ||
provider billed for services rendered.
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(h) Nothing in this Section shall be interpreted to change | ||
the prudent layperson provisions with respect to emergency | ||
services under the Managed Care Reform and Patient Rights Act. | ||
(Source: P.A. 96-1523, eff. 6-1-11.)
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Section 99. Effective date. This Act takes effect upon | ||
becoming law.
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