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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) 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
of | ||||||
| 14 | the patient; the date of service; the service code or if no | ||||||
| 15 | service code is
available a service description;
the recoupment | ||||||
| 16 | amount; and the reason for the recoupment or offset. In
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| 17 | addition,
an insurer,
health maintenance organization, | ||||||
| 18 | independent
practice association, or physician
hospital | ||||||
| 19 | organization shall provide with the remittance advice, or with | ||||||
| 20 | any demand for recoupment or offset, a telephone
number or | ||||||
| 21 | mailing address to initiate an appeal of the recoupment or | ||||||
| 22 | offset together with the deadline for initiating an appeal. | ||||||
| 23 | Such information shall be prominently displayed on the | ||||||
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| 1 | remittance advice or written document containing the demand for | ||||||
| 2 | recoupment or offset. Any appeal of a recoupment or offset by a | ||||||
| 3 | health care professional or health care provider must be made | ||||||
| 4 | within 60 days after receipt of the remittance advice.
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| 5 | (b) It is not a recoupment when a health care professional | ||||||
| 6 | or health care
provider
is paid an amount prospectively or | ||||||
| 7 | concurrently under a contract with an
insurer, health
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| 8 | maintenance organization, independent practice
association, or | ||||||
| 9 | physician
hospital
organization that requires a retrospective | ||||||
| 10 | reconciliation based upon specific
conditions
outlined in the | ||||||
| 11 | contract.
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| 12 | (c) No recoupment or offset may be requested or withheld | ||||||
| 13 | from future payments 18 months or more after the original | ||||||
| 14 | payment is made, except in cases in which: | ||||||
| 15 | (1) a court, government administrative agency, other | ||||||
| 16 | tribunal, or independent third-party arbitrator makes or | ||||||
| 17 | has made a formal finding of fraud or material | ||||||
| 18 | misrepresentation; | ||||||
| 19 | (2) an insurer is acting as a plan administrator for | ||||||
| 20 | the Comprehensive Health Insurance Plan under the | ||||||
| 21 | Comprehensive Health Insurance Plan Act; or | ||||||
| 22 | (3) the provider has already been paid in full by any | ||||||
| 23 | other payer, third party, or workers' compensation | ||||||
| 24 | insurer. | ||||||
| 25 | No contract between an insurer and a health care professional | ||||||
| 26 | or health care provider may provide for recoupments in | ||||||
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| 1 | violation of this Section. Nothing in this Section shall be | ||||||
| 2 | construed to preclude insurers, health maintenance | ||||||
| 3 | organizations, independent practice associations, or physician | ||||||
| 4 | hospital organizations from resolving coordination of benefits | ||||||
| 5 | between or among each other, including, but not limited to, | ||||||
| 6 | resolution of workers' compensation and third-party liability | ||||||
| 7 | cases, without recouping payment from the provider beyond the | ||||||
| 8 | 18-month time limit provided in this subsection (c). | ||||||
| 9 | (Source: P.A. 93-261, eff. 1-1-04.)
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