Full Text of HB1193 97th General Assembly
HB1193enr 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: | 15 | | (1) a court, government administrative agency, other | 16 | | tribunal, or independent third-party arbitrator makes or | 17 | | has made a formal finding of fraud or material | 18 | | misrepresentation; | 19 | | (2) an insurer is acting as a plan administrator for | 20 | | the Comprehensive Health Insurance Plan under the | 21 | | Comprehensive Health Insurance Plan Act; or | 22 | | (3) the provider has already been paid in full by any | 23 | | other payer, third party, or workers' compensation | 24 | | insurer. | 25 | | No contract between an insurer and a health care professional | 26 | | or health care provider may provide for recoupments in |
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| 1 | | violation of this Section. Nothing in this Section shall be | 2 | | construed to preclude insurers, health maintenance | 3 | | organizations, independent practice associations, or physician | 4 | | hospital organizations from resolving coordination of benefits | 5 | | between or among each other, including, but not limited to, | 6 | | resolution of workers' compensation and third-party liability | 7 | | cases, without recouping payment from the provider beyond the | 8 | | 18-month time limit provided in this subsection (c). | 9 | | (Source: P.A. 93-261, eff. 1-1-04.)
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