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1 | AN ACT concerning insurance.
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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) Except in cases of fraud, all claims paid by an | |||||||||||||||||||
9 | insurer, health maintenance organization, independent practice | |||||||||||||||||||
10 | association, or physician hospital organization shall be | |||||||||||||||||||
11 | considered final unless adjustments are made pursuant to this | |||||||||||||||||||
12 | Section 368d. A health care professional or health care | |||||||||||||||||||
13 | provider shall be provided a
remittance advice, which must | |||||||||||||||||||
14 | include an explanation of a
recoupment or
offset taken by an | |||||||||||||||||||
15 | insurer, health maintenance organization,
independent practice | |||||||||||||||||||
16 | association, or physician hospital
organization, if any. The | |||||||||||||||||||
17 | recoupment explanation shall, at a minimum, include
the name
of | |||||||||||||||||||
18 | the patient; the date of service; the service code or if no | |||||||||||||||||||
19 | service code is
available a service description;
the recoupment | |||||||||||||||||||
20 | amount; and the reason for the recoupment or offset. In
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21 | addition,
an insurer,
health maintenance organization, | |||||||||||||||||||
22 | independent
practice association, or physician
hospital | |||||||||||||||||||
23 | organization shall provide with the remittance advice a |
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1 | telephone
number or mailing address to initiate an appeal of | ||||||
2 | the recoupment or offset.
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3 | (b) If an insurer, health maintenance organization, | ||||||
4 | independent practice association, or physician hospital | ||||||
5 | organization determines that it has made an overpayment to a | ||||||
6 | provider for services rendered to an insured, the insurer must | ||||||
7 | give the provider a written statement specifying the basis for | ||||||
8 | the claim of overpayment and identifying the claim or claims | ||||||
9 | and the overpayment portion that is claimed. The written | ||||||
10 | statement shall include the following: the name of the patient; | ||||||
11 | the date or dates of service; the service code or, if no | ||||||
12 | service code is available, a service description; and the | ||||||
13 | amount of claimed overpayment. In addition, an insurer, health | ||||||
14 | maintenance organization, independent practice association, or | ||||||
15 | physician hospital organization shall provide the provider | ||||||
16 | with a telephone number or mailing address to initiate an | ||||||
17 | appeal of the claimed overpayment. It is not a recoupment when | ||||||
18 | a health care professional or health care
provider
is paid an | ||||||
19 | amount prospectively or concurrently under a contract with an
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20 | insurer, health
maintenance organization, independent practice
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21 | association, or physician
hospital
organization that requires | ||||||
22 | a retrospective reconciliation based upon specific
conditions
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23 | outlined in the contract.
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24 | (c) Where there is a contract between the provider and the | ||||||
25 | insurer, adjustments to claims shall be made within the time | ||||||
26 | period set out in the contract between the provider and the |
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1 | insurer, unless otherwise agreed to in writing by the provider | ||||||
2 | and the insurer. The time period agreed to in writing shall not | ||||||
3 | exceed 6 months after the date the claim was submitted. | ||||||
4 | (d) Where there is no contract between a provider and an | ||||||
5 | insurer, health maintenance organization, independent practice | ||||||
6 | association, or physician hospital organization, adjustments | ||||||
7 | to claims shall be made within 6 months after the date the | ||||||
8 | claim was submitted, unless otherwise agreed to in writing by | ||||||
9 | the provider and the insurer. | ||||||
10 | (e) An insurer, health maintenance organization, | ||||||
11 | independent practice association, or physician hospital | ||||||
12 | organization shall not seek recoupment for payment of a claim | ||||||
13 | based on claimed lack of eligibility if the insurer verified | ||||||
14 | eligibility of the patient prior to payment of the claim. | ||||||
15 | (f) An insurer, health maintenance organization, | ||||||
16 | independent practice association, or physician hospital | ||||||
17 | organization shall not seek recoupment for payment of a claim | ||||||
18 | based on any claimed lack of medical necessity if the insurer | ||||||
19 | has received the provider's treatment records for the patient | ||||||
20 | prior to issuing payment. | ||||||
21 | (g) An insurer, health maintenance organization, | ||||||
22 | independent practice association, or physician hospital | ||||||
23 | organization shall not offset payment for claims for services | ||||||
24 | to a patient against claims for the provider's services to any | ||||||
25 | other patient or patients. | ||||||
26 | (h) If an insurer, health maintenance organization, |
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1 | independent practice association, or physician hospital | ||||||
2 | organization reviews or makes a determination of medical | ||||||
3 | necessity or any other medical issue, it shall be conducted by | ||||||
4 | a person of identical licensure as the provider. | ||||||
5 | (i) This Section does not apply to reconciliations made | ||||||
6 | under specific conditions outlined in health maintenance | ||||||
7 | organization provider agreements under which health care | ||||||
8 | professionals or health care providers are paid prospectively | ||||||
9 | or concurrently per capita. | ||||||
10 | (Source: P.A. 93-261, eff. 1-1-04.)
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