Full Text of HB1193 97th General Assembly
HB1193ham001 97TH GENERAL ASSEMBLY | Rep. Greg Harris Filed: 4/7/2011
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| 1 | | AMENDMENT TO HOUSE BILL 1193
| 2 | | AMENDMENT NO. ______. Amend House Bill 1193 by replacing | 3 | | everything after the enacting clause with the following:
| 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
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| 1 | | addition,
an insurer,
health maintenance organization, | 2 | | independent
practice association, or physician
hospital | 3 | | organization shall provide with the remittance advice , or with | 4 | | any demand for recoupment or offset, a telephone
number or | 5 | | mailing address to initiate an appeal of the recoupment or | 6 | | offset together with the deadline for initiating an appeal . | 7 | | Such information shall be prominently displayed on the | 8 | | remittance advice or written document containing the demand for | 9 | | recoupment or offset. Any appeal of a recoupment or offset by a | 10 | | health care professional or health care provider must be made | 11 | | within 60 days after receipt of the remittance advice.
| 12 | | (b) It is not a recoupment when a health care professional | 13 | | or health care
provider
is paid an amount prospectively or | 14 | | concurrently under a contract with an
insurer, health
| 15 | | maintenance organization, independent practice
association, or | 16 | | physician
hospital
organization that requires a retrospective | 17 | | reconciliation based upon specific
conditions
outlined in the | 18 | | contract.
| 19 | | (c) No recoupment or offset may be requested or withheld | 20 | | from future payments 18 months or more after the original | 21 | | payment is made, except in cases in which a court, government | 22 | | administrative agency, or other tribunal has made a formal | 23 | | adjudication of fraud or misrepresentation or in cases in which | 24 | | an insurer is acting as a plan administrator for the | 25 | | Comprehensive Health Insurance Plan under the Comprehensive | 26 | | Health Insurance Plan Act or, in cases in which the provider |
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| 1 | | has already been paid in full, by any other payer, third party, | 2 | | or workers' compensation insurer. No contract between an | 3 | | insurer and a health care professional or health care provider | 4 | | may provide for recoupments in violation of this Section. | 5 | | Nothing in this Section shall be construed to preclude | 6 | | insurers, health maintenance organizations, independent | 7 | | practice associations, or physician hospital organizations | 8 | | from resolving coordination of benefits between or among each | 9 | | other, including, but not limited to, resolution of workers' | 10 | | compensation and third-party liability cases, without | 11 | | recouping payment from the provider beyond the 18-month time | 12 | | limit provided in this subsection (c). | 13 | | (Source: P.A. 93-261, eff. 1-1-04.)".
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