Full Text of HB1193 97th General Assembly
HB1193eng 97TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning insurance.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 368d as follows:
| 6 | | (215 ILCS 5/368d)
| 7 | | Sec. 368d. Recoupments.
| 8 | | (a) A health care professional or health care provider | 9 | | shall be provided a
remittance advice, which must include an | 10 | | explanation of a
recoupment or
offset taken by an insurer, | 11 | | health maintenance organization,
independent practice | 12 | | association, or physician hospital
organization, if any. The | 13 | | recoupment explanation shall, at a minimum, include
the name
of | 14 | | the patient; the date of service; the service code or if no | 15 | | service code is
available a service description;
the recoupment | 16 | | amount; and the reason for the recoupment or offset. In
| 17 | | addition,
an insurer,
health maintenance organization, | 18 | | independent
practice association, or physician
hospital | 19 | | organization shall provide with the remittance advice , or with | 20 | | any demand for recoupment or offset, a telephone
number or | 21 | | mailing address to initiate an appeal of the recoupment or | 22 | | offset together with the deadline for initiating an appeal . | 23 | | Such information shall be prominently displayed on the |
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| 1 | | remittance advice or written document containing the demand for | 2 | | recoupment or offset. Any appeal of a recoupment or offset by a | 3 | | health care professional or health care provider must be made | 4 | | within 60 days after receipt of the remittance advice.
| 5 | | (b) It is not a recoupment when a health care professional | 6 | | or health care
provider
is paid an amount prospectively or | 7 | | concurrently under a contract with an
insurer, health
| 8 | | maintenance organization, independent practice
association, or | 9 | | physician
hospital
organization that requires a retrospective | 10 | | reconciliation based upon specific
conditions
outlined in the | 11 | | contract.
| 12 | | (c) No recoupment or offset may be requested or withheld | 13 | | from future payments 18 months or more after the original | 14 | | payment is made, except in cases in which a court, government | 15 | | administrative agency, or other tribunal has made a formal | 16 | | adjudication of fraud or misrepresentation or in cases in which | 17 | | an insurer is acting as a plan administrator for the | 18 | | Comprehensive Health Insurance Plan under the Comprehensive | 19 | | Health Insurance Plan Act or, in cases in which the provider | 20 | | has already been paid in full, by any other payer, third party, | 21 | | or workers' compensation insurer. No contract between an | 22 | | insurer and a health care professional or health care provider | 23 | | may provide for recoupments in violation of this Section. | 24 | | Nothing in this Section shall be construed to preclude | 25 | | insurers, health maintenance organizations, independent | 26 | | practice associations, or physician hospital organizations |
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| 1 | | from resolving coordination of benefits between or among each | 2 | | other, including, but not limited to, resolution of workers' | 3 | | compensation and third-party liability cases, without | 4 | | recouping payment from the provider beyond the 18-month time | 5 | | limit provided in this subsection (c). | 6 | | (Source: P.A. 93-261, eff. 1-1-04.)
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