97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB1193

 

Introduced 02/08/11, by Rep. Greg Harris

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/368d

    Amends the Illinois Insurance Code. In the provision concerning recoupment, provides that no recoupment or offset may be requested or withheld from future payments 366 or more days after the original payment. Provides for exceptions for cases in which there has been a formal adjudication of fraud or the provider has already been paid in full. Provides that nothing in the provision concerning recoupments shall be construed to preclude insurers or certain organizations from resolving coordination of benefits between or among each other without recouping payment from the provider beyond the 366-day time limit.


LRB097 05476 RPM 45536 b

 

 

A BILL FOR

 

HB1193LRB097 05476 RPM 45536 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 368d as follows:
 
6    (215 ILCS 5/368d)
7    Sec. 368d. Recoupments.
8    (a) A health care professional or health care provider
9shall be provided a remittance advice, which must include an
10explanation of a recoupment or offset taken by an insurer,
11health maintenance organization, independent practice
12association, or physician hospital organization, if any. The
13recoupment explanation shall, at a minimum, include the name of
14the patient; the date of service; the service code or if no
15service code is available a service description; the recoupment
16amount; and the reason for the recoupment or offset. In
17addition, an insurer, health maintenance organization,
18independent practice association, or physician hospital
19organization shall provide with the remittance advice a
20telephone number or mailing address to initiate an appeal of
21the recoupment or offset.
22    (b) It is not a recoupment when a health care professional
23or health care provider is paid an amount prospectively or

 

 

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1concurrently under a contract with an insurer, health
2maintenance organization, independent practice association, or
3physician hospital organization that requires a retrospective
4reconciliation based upon specific conditions outlined in the
5contract.
6    (c) No recoupment or offset may be requested or withheld
7from future payments 366 or more days after the original
8payment is made, except in cases in which a court, government
9administrative agency, or other tribunal has made a formal
10adjudication of fraud or in cases in which the provider has
11already been paid in full by another payor or by a workers'
12compensation insurer. No contract between an insurer and a
13health care professional or health care provider may provide
14for recoupments in violation of this Section. Nothing in this
15Section shall be construed to preclude insurers, health
16maintenance organizations, independent practice associations,
17or physician hospital organizations from resolving
18coordination of benefits between or among each other without
19recouping payment from the provider beyond the 366-day time
20limit provided in this subsection.
21(Source: P.A. 93-261, eff. 1-1-04.)