94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB4113

 

Introduced 09/20/05, by Rep. William B. Black

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/368c
215 ILCS 5/368f new

    Amends the Illinois Insurance Code. Requires health insurers to provide certain information to the insured and the health care professional or provider when prospectively denying or certifying medical care. Makes other changes.


LRB094 13983 LJB 48864 b

 

 

A BILL FOR

 

HB4113 LRB094 13983 LJB 48864 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 368c and by adding Section 368f as follows:
 
6     (215 ILCS 5/368c)
7     Sec. 368c. Remittance advice and procedures.
8     (a) A remittance advice shall be furnished to a health care
9 professional or health care provider that identifies the
10 disposition of each claim. The remittance advice shall identify
11 the services billed; the patient responsibility, if any; the
12 actual payment, if any, for the services billed; and the reason
13 for any reduction to the amount for which the claim was
14 submitted. For any reductions to the amount for which the claim
15 was submitted, the remittance shall identify any withholds and
16 the reason for any denial or reduction.
17     A remittance advice for capitation or prospective payment
18 arrangements shall be furnished to a health care professional
19 or health care provider pursuant to a contract with an insurer,
20 health maintenance organization, independent practice
21 association, or physician hospital organization in accordance
22 with the terms of the contract.
23     (b) When health care services are provided by a
24 non-participating health care professional or health care
25 provider, an insurer, health maintenance organization,
26 independent practice association, or physician hospital
27 organization may pay for covered services either to a patient
28 directly or to the non-participating health care professional
29 or health care provider.
30     (c) When a person presents a benefits information card to a
31 health care professional or health care provider, the a health
32 care professional or health care provider shall make a good

 

 

HB4113 - 2 - LRB094 13983 LJB 48864 b

1 faith effort to inform the person if the health care
2 professional or health care provider has a participation
3 contract with the insurer, health maintenance organization, or
4 other entity identified on the card.
5 (Source: P.A. 93-261, eff. 1-1-04.)
 
6     (215 ILCS 5/368f new)
7     Sec. 368f. Prospective denial and certification of
8 coverage.
9     (a) An insurer that prospectively denies coverage for
10 medical treatment shall provide to the insured and the health
11 care professional or health care provider a statement of the
12 reasons for the denial, including, but not limited to, that the
13 medical care is not covered under the insured's contract with
14 the insurer or the professional or provider is not contracted
15 with the insurer or is out-of-network. If the basis for denial
16 is that the professional or provider is not contracted with the
17 insurer, the insurer shall provide the insured with a list of
18 professionals and providers that are contracted with the
19 insurer or are in-network in the geographic area within which
20 the insured is seeking treatment.
21     (b) An insurer that prospectively certifies coverage for
22 medical treatment shall provide the insured and the health care
23 professional or health care provider with a statement providing
24 details of coverage, including, but not limited to, what is
25 covered under the insured's contract with the insurer, the rate
26 or percentage at which the insurer will reimburse the
27 professional or provider for the services, and the
28 professionals and providers that are considered in-network by
29 the insurer in the geographic area in which the insured is
30 seeking treatment.
31     (c) As used in this Section, "insurer" means a health
32 insurer, health maintenance organization, independent practice
33 association, physician hospital organization, preferred
34 provider organization, or any other organization that provides
35 or arranges for one or more health care plans under a system

 

 

HB4113 - 3 - LRB094 13983 LJB 48864 b

1 that causes any part of the risk of health care delivery to be
2 borne by the organization or its providers.