Full Text of SB1974 102nd General Assembly
SB1974eng 102ND GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 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
| 14 | | of the patient; the date of service; the service code or if no | 15 | | service code is
available a service description;
the | 16 | | recoupment amount; and the reason for the recoupment or | 17 | | offset. In
addition,
an insurer,
health maintenance | 18 | | organization, independent
practice association, or physician
| 19 | | hospital organization shall provide with the remittance | 20 | | advice, or with any demand for recoupment or offset, a | 21 | | telephone
number or mailing address to initiate an appeal of | 22 | | the recoupment or offset together with the deadline for | 23 | | initiating an appeal. Such information shall be prominently |
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| 1 | | displayed on the remittance advice or written document | 2 | | containing the demand for recoupment or offset. Any appeal of | 3 | | a recoupment or offset by a health care professional or health | 4 | | care provider must be made within 60 days after receipt of the | 5 | | remittance advice.
| 6 | | (b) It is not a recoupment when a health care professional | 7 | | or health care
provider
is paid an amount prospectively or | 8 | | concurrently under a contract with an
insurer, health
| 9 | | maintenance organization, independent practice
association, or | 10 | | physician
hospital
organization that requires a retrospective | 11 | | reconciliation based upon specific
conditions
outlined in the | 12 | | contract.
| 13 | | (c) No recoupment or offset may be requested or withheld | 14 | | from future payments 12 18 months or more after the original | 15 | | payment is made, except in cases in which: | 16 | | (1) a court, government administrative agency, other | 17 | | tribunal, or independent third-party arbitrator makes or | 18 | | has made a formal finding of fraud or material | 19 | | misrepresentation; | 20 | | (2) an insurer is acting as a plan administrator for | 21 | | the Comprehensive Health Insurance Plan under the | 22 | | Comprehensive Health Insurance Plan Act; or | 23 | | (3) the provider has already been paid in full by any | 24 | | other payer, third party, or workers' compensation | 25 | | insurer. | 26 | | No contract between an insurer and a health care professional |
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| 1 | | or health care provider may provide for recoupments in | 2 | | violation of this Section. Nothing in this Section shall be | 3 | | construed to preclude insurers, health maintenance | 4 | | organizations, independent practice associations, or physician | 5 | | hospital organizations from resolving coordination of benefits | 6 | | between or among each other, including, but not limited to, | 7 | | resolution of workers' compensation and third-party liability | 8 | | cases, without recouping payment from the provider beyond the | 9 | | 18-month time limit provided in this subsection (c). | 10 | | (Source: P.A. 97-556, eff. 1-1-12.)
| 11 | | Section 99. Effective date. This Act takes effect January | 12 | | 1, 2022.
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