HB5107ham001 96TH GENERAL ASSEMBLY

Insurance Committee

Filed: 3/9/2010

09600HB5107ham001 LRB096 18006 RPM 37703 a

AMENDMENT TO HOUSE BILL 5107

AMENDMENT NO. ______. Amend House Bill 5107 by replacing everything after the enacting clause with the following:

"Section 5. The Illinois Insurance Code is amended by changing Section 368d as follows:

(215 ILCS 5/368d)

Sec. 368d. Recoupments.

(a) A health care professional or health care provider shall be provided a remittance advice, which must include an explanation of a recoupment or offset taken by an insurer, health maintenance organization, independent practice association, or physician hospital organization, if any. The recoupment explanation shall, at a minimum, include the name of the patient; the date of service; the service code or if no service code is available a service description; the recoupment amount; and the reason for the recoupment or offset. In addition, an insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide with the remittance advice a telephone number or mailing address to initiate an appeal of the recoupment or offset.

(b) It is not a recoupment when a health care professional or health care provider is paid an amount prospectively or concurrently under a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization that requires a retrospective reconciliation based upon specific conditions outlined in the contract.

(c) No recoupment or offset may be requested or withheld from future payments 366 or more days after the original payment is made, except in cases where a court, government administrative agency, or other tribunal has made a formal adjudication of fraud. No contract between an insurer and a health care professional or health care provider may provide for recoupments in violation of this Section.

(Source: P.A. 93-261, eff. 1-1-04.)".