Insurance Committee

Filed: 3/9/2010

 

 


 

 


 
09600HB5107ham001 LRB096 18006 RPM 37703 a

1
AMENDMENT TO HOUSE BILL 5107

2     AMENDMENT NO. ______. Amend House Bill 5107 by replacing
3 everything after the enacting clause with the following:
 
4     "Section 5. The Illinois Insurance Code is amended by
5 changing Section 368d as follows:
 
6     (215 ILCS 5/368d)
7     Sec. 368d. Recoupments.
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

 

 

09600HB5107ham001 - 2 - LRB096 18006 RPM 37703 a

1 addition, an insurer, health maintenance organization,
2 independent practice association, or physician hospital
3 organization shall provide with the remittance advice a
4 telephone number or mailing address to initiate an appeal of
5 the recoupment or offset.
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
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.
13     (c) No recoupment or offset may be requested or withheld
14 from future payments 366 or more days after the original
15 payment is made, except in cases where a court, government
16 administrative agency, or other tribunal has made a formal
17 adjudication of fraud. No contract between an insurer and a
18 health care professional or health care provider may provide
19 for recoupments in violation of this Section.
20 (Source: P.A. 93-261, eff. 1-1-04.)".