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| 1 | AN ACT concerning regulation.
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| 2 | Be it enacted by the People of the State of Illinois,
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| 3 | represented in the General Assembly:
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| 4 | Section 5. The Illinois Insurance Code is amended by | ||||||
| 5 | changing Section 368d as follows:
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| 6 | (215 ILCS 5/368d)
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| 7 | Sec. 368d. Recoupments.
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| 8 | (a) A health care professional or health care provider | ||||||
| 9 | shall be provided a
remittance advice, which must include an | ||||||
| 10 | explanation of a
recoupment or
offset taken by an insurer, | ||||||
| 11 | health maintenance organization,
independent practice | ||||||
| 12 | association, or physician hospital
organization, if any. The | ||||||
| 13 | recoupment explanation shall, at a minimum, include
the name
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| 14 | of the patient; the date of service; the service code or if no | ||||||
| 15 | service code is
available a service description;
the | ||||||
| 16 | recoupment amount; and the reason for the recoupment or | ||||||
| 17 | offset. In
addition,
an insurer,
health maintenance | ||||||
| 18 | organization, independent
practice association, or physician
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| 19 | hospital organization shall provide with the remittance | ||||||
| 20 | advice, or with any demand for recoupment or offset, a | ||||||
| 21 | telephone
number or mailing address to initiate an appeal of | ||||||
| 22 | the recoupment or offset together with the deadline for | ||||||
| 23 | initiating an appeal. Such information shall be prominently | ||||||
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| 1 | displayed on the remittance advice or written document | ||||||
| 2 | containing the demand for recoupment or offset. Any appeal of | ||||||
| 3 | a recoupment or offset by a health care professional or health | ||||||
| 4 | care provider must be made within 60 days after receipt of the | ||||||
| 5 | remittance advice.
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| 6 | (b) It is not a recoupment when a health care professional | ||||||
| 7 | or health care
provider
is paid an amount prospectively or | ||||||
| 8 | concurrently under a contract with an
insurer, health
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| 9 | maintenance organization, independent practice
association, or | ||||||
| 10 | physician
hospital
organization that requires a retrospective | ||||||
| 11 | reconciliation based upon specific
conditions
outlined in the | ||||||
| 12 | contract.
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| 13 | (c) No recoupment or offset may be requested or withheld | ||||||
| 14 | from future payments 12 18 months or more after the original | ||||||
| 15 | payment is made, except in cases in which: | ||||||
| 16 | (1) a court, government administrative agency, other | ||||||
| 17 | tribunal, or independent third-party arbitrator makes or | ||||||
| 18 | has made a formal finding of fraud or material | ||||||
| 19 | misrepresentation; | ||||||
| 20 | (2) an insurer is acting as a plan administrator for | ||||||
| 21 | the Comprehensive Health Insurance Plan under the | ||||||
| 22 | Comprehensive Health Insurance Plan Act; or | ||||||
| 23 | (3) the provider has already been paid in full by any | ||||||
| 24 | other payer, third party, or workers' compensation | ||||||
| 25 | insurer; or . | ||||||
| 26 | (4) an insurer contracted with the Department of | ||||||
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| 1 | Healthcare and Family Services is required by the | ||||||
| 2 | Department of Healthcare and Family Services to recoup or | ||||||
| 3 | offset payments due to a federal Medicaid requirement. | ||||||
| 4 | No contract between an insurer and a health care professional | ||||||
| 5 | or health care provider may provide for recoupments in | ||||||
| 6 | violation of this Section. Nothing in this Section shall be | ||||||
| 7 | construed to preclude insurers, health maintenance | ||||||
| 8 | organizations, independent practice associations, or physician | ||||||
| 9 | hospital organizations from resolving coordination of benefits | ||||||
| 10 | between or among each other, including, but not limited to, | ||||||
| 11 | resolution of workers' compensation and third-party liability | ||||||
| 12 | cases, without recouping payment from the provider beyond the | ||||||
| 13 | 18-month time limit provided in this subsection (c). | ||||||
| 14 | (Source: P.A. 97-556, eff. 1-1-12.)
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| 15 | Section 99. Effective date. This Act takes effect January | ||||||
| 16 | 1, 2022.
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