98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB1642

 

Introduced 2/13/2013, by Sen. Mattie Hunter

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/143.31
215 ILCS 5/368c

    Amends the Illinois Insurance Code. Makes changes to the provision concerning the required content in (1) explanation of benefits paid statements and (2) claims summary statements sent to an insured by their accident and health insurer. Makes changes to the provision concerning the remittance advice that is furnished to a health care professional or health care provider.


LRB098 08861 RPM 38991 b

 

 

A BILL FOR

 

SB1642LRB098 08861 RPM 38991 b

1    AN ACT concerning regulation.
 
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 Sections 143.31 and 368c as follows:
 
6    (215 ILCS 5/143.31)
7    Sec. 143.31. Uniform medical claim and billing forms.
8    (a) The Director shall prescribe by rule, after
9consultation with providers of health care or treatment,
10insurers, hospital, medical, and dental service corporations,
11and other prepayment organizations, insurance claim and
12billing forms that the Director determines will provide for
13uniformity and simplicity in insurance claims handling. The
14claim forms shall include, but need not be limited to,
15information regarding the medical diagnosis, treatment, and
16prognosis of the patient, together with the details of charges
17incident to the providing of care, treatment, or services,
18sufficient for the purpose of meeting the proof requirements of
19an insurance policy or a hospital, medical, or dental service
20contract.
21    (b) An insurer or a provider of health care treatment may
22not refuse to accept a claim or bill submitted on duly
23promulgated uniform claim and billing forms. An insurer,

 

 

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1however, may accept claims and bills submitted on any other
2form.
3    (c) Accident and health insurer explanation of benefits
4paid statements or claims summary statements sent to an insured
5by the accident and health insurer shall be in a format and
6written in a manner that promotes understanding by the insured
7by setting forth all of the following:
8        (1) The total dollar amount submitted to the insurer
9    for payment.
10        (2) Any reduction in the amount paid. For any
11    reductions to the amount for which the claim was submitted,
12    the explanation of benefits shall identify separately in
13    clearly marked columns any and all withholds and the reason
14    for any denial or reduction, including, but not limited to,
15    deductibles, copayments, coinsurance, and administrative
16    fees of any kind due to the application of any co-payment
17    or deductible, along with an explanation of the amount of
18    the co-payment or deductible applied under the insured's
19    policy.
20        (3) Any reduction in the amount paid due to the
21    application of any other policy limitation or exclusion set
22    forth in the insured's policy, along with an explanation
23    thereof.
24        (4) The total dollar amount paid.
25        (5) The total dollar amount remaining unpaid.
26    The items and amounts shown on any health care explanation

 

 

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1of benefits must match and be consistent with the items and
2amounts on the corresponding remittance advice sent to a health
3care provider, such that the explanation of benefits clearly
4discloses to the patient all reductions in the actual amount
5paid to a provider.
6    No payer may issue an explanation of benefits stating
7payment has been made to a provider unless and until actual
8payment has been made. If actual payment will not be made
9promptly as provided in Section 368a of this Code, a payer
10shall issue a preliminary explanation of benefits stating that
11payment is anticipated in a specified amount and a second
12explanation of benefits when actual payment has been made.
13    (d) The Director may issue an order directing an accident
14and health insurer to comply with subsection (c).
15    (e) An accident and health insurer does not violate
16subsection (c) by using a document that the accident and health
17insurer is required to use by the federal government or the
18State.
19    (f) The adoption of uniform claim forms and uniform billing
20forms by the Director under this Section does not preclude an
21insurer, hospital, medical, or dental service corporation, or
22other prepayment organization from obtaining any necessary
23additional information regarding a claim from the claimant,
24provider of health care or treatment, or certifier of coverage,
25as may be required.
26    (g) On and after January 1, 1996 when billing insurers or

 

 

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1otherwise filing insurance claims with insurers subject to this
2Section, providers of health care or treatment, medical
3services, dental services, pharmaceutical services, or medical
4equipment must use the uniform claim and billing forms adopted
5by the Director under this Section.
6(Source: P.A. 91-357, eff. 7-29-99.)
 
7    (215 ILCS 5/368c)
8    Sec. 368c. Remittance advice and procedures.
9    (a) Payors, including, but not limited to, insurers, health
10maintenance organizations, managed care plans, health care
11plans, preferred provider organizations, third party
12administrators, independent practice associations, and
13physician-hospital organizations, shall furnish a health care
14professional or health care provider with a A remittance advice
15shall be furnished to a health care professional or health care
16provider that identifies the disposition of each claim. The
17remittance advice shall identify the services billed; the
18patient responsibility, if any; the actual payment, if any, for
19the services billed; and the reason for any reduction to the
20amount for which the claim was submitted. For any reductions to
21the amount for which the claim was submitted, the remittance
22shall identify separately any and all withholds in clearly
23marked columns any withholds and the reason for any denial or
24reduction, including, but not limited to, deductibles,
25copayments, coinsurance, and administrative fees of any kind.

 

 

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1    A remittance advice for capitation or prospective payment
2arrangements shall be furnished to a health care professional
3or health care provider pursuant to a contract with an insurer,
4health maintenance organization, independent practice
5association, or physician hospital organization in accordance
6with the terms of the contract; provided, however, no such
7contract shall contain terms in violation of this Section. In
8the event of a conflict between a provider contract and this
9Section, this Section shall prevail.
10    (b) When health care services are provided by a
11non-participating health care professional or health care
12provider, an insurer, health maintenance organization,
13independent practice association, or physician hospital
14organization may pay for covered services either to a patient
15directly or to the non-participating health care professional
16or health care provider.
17    (c) When a person presents a benefits information card, a
18health care professional or health care provider shall make a
19good faith effort to inform the person if the health care
20professional or health care provider has a participation
21contract with the insurer, health maintenance organization, or
22other entity identified on the card.
23(Source: P.A. 93-261, eff. 1-1-04.)