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


Rep. Greg Harris

Filed: 4/7/2011





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2    AMENDMENT NO. ______. Amend House Bill 1193 by replacing
3everything after the enacting clause with the following:
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



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1addition, an insurer, health maintenance organization,
2independent practice association, or physician hospital
3organization shall provide with the remittance advice, or with
4any demand for recoupment or offset, a telephone number or
5mailing address to initiate an appeal of the recoupment or
6offset together with the deadline for initiating an appeal.
7Such information shall be prominently displayed on the
8remittance advice or written document containing the demand for
9recoupment or offset. Any appeal of a recoupment or offset by a
10health care professional or health care provider must be made
11within 60 days after receipt of the remittance advice.
12    (b) It is not a recoupment when a health care professional
13or health care provider is paid an amount prospectively or
14concurrently under a contract with an insurer, health
15maintenance organization, independent practice association, or
16physician hospital organization that requires a retrospective
17reconciliation based upon specific conditions outlined in the
19    (c) No recoupment or offset may be requested or withheld
20from future payments 18 months or more after the original
21payment is made, except in cases in which a court, government
22administrative agency, or other tribunal has made a formal
23adjudication of fraud or misrepresentation or in cases in which
24an insurer is acting as a plan administrator for the
25Comprehensive Health Insurance Plan under the Comprehensive
26Health Insurance Plan Act or, in cases in which the provider



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1has already been paid in full, by any other payer, third party,
2or workers' compensation insurer. No contract between an
3insurer and a health care professional or health care provider
4may provide for recoupments in violation of this Section.
5Nothing in this Section shall be construed to preclude
6insurers, health maintenance organizations, independent
7practice associations, or physician hospital organizations
8from resolving coordination of benefits between or among each
9other, including, but not limited to, resolution of workers'
10compensation and third-party liability cases, without
11recouping payment from the provider beyond the 18-month time
12limit provided in this subsection (c).
13(Source: P.A. 93-261, eff. 1-1-04.)".