Illinois General Assembly - Full Text of HB1193
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Full Text of HB1193  97th General Assembly




HB1193 EnrolledLRB097 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, or with
20any demand for recoupment or offset, a telephone number or
21mailing address to initiate an appeal of the recoupment or
22offset together with the deadline for initiating an appeal.
23Such information shall be prominently displayed on the



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1remittance advice or written document containing the demand for
2recoupment or offset. Any appeal of a recoupment or offset by a
3health care professional or health care provider must be made
4within 60 days after receipt of the remittance advice.
5    (b) It is not a recoupment when a health care professional
6or health care provider is paid an amount prospectively or
7concurrently under a contract with an insurer, health
8maintenance organization, independent practice association, or
9physician hospital organization that requires a retrospective
10reconciliation based upon specific conditions outlined in the
12    (c) No recoupment or offset may be requested or withheld
13from future payments 18 months or more after the original
14payment 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.
25No contract between an insurer and a health care professional
26or health care provider may provide for recoupments in



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1violation of this Section. Nothing in this Section shall be
2construed to preclude insurers, health maintenance
3organizations, independent practice associations, or physician
4hospital organizations from resolving coordination of benefits
5between or among each other, including, but not limited to,
6resolution of workers' compensation and third-party liability
7cases, without recouping payment from the provider beyond the
818-month time limit provided in this subsection (c).
9(Source: P.A. 93-261, eff. 1-1-04.)