Full Text of HB4113 94th General Assembly
HB4113 94TH GENERAL ASSEMBLY
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94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006 HB4113
Introduced 09/20/05, by Rep. William B. Black SYNOPSIS AS INTRODUCED: |
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215 ILCS 5/368c |
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215 ILCS 5/368f new |
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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.
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A BILL FOR
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HB4113 |
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LRB094 13983 LJB 48864 b |
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 5. The Illinois Insurance Code is amended by | 5 |
| changing Section 368c and by adding Section 368f as follows:
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| (215 ILCS 5/368c)
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| Sec. 368c. Remittance advice and procedures.
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| (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.
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| 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.
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| (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,
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| 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.
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| (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 |
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HB4113 |
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LRB094 13983 LJB 48864 b |
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| 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.
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| (Source: P.A. 93-261, eff. 1-1-04.)
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| (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 |
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HB4113 |
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LRB094 13983 LJB 48864 b |
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| that causes any part of the risk of health care delivery to be | 2 |
| borne by the organization or its providers.
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