Full Text of SB1658 98th General Assembly
SB1658enr 98TH 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 356z.3a as follows: | 6 | | (215 ILCS 5/356z.3a) | 7 | | Sec. 356z.3a. Nonparticipating facility-based physicians | 8 | | and providers. | 9 | | (a) For purposes of this Section, "facility-based | 10 | | provider" means a physician or other provider who provide | 11 | | radiology, anesthesiology, pathology, neonatology, or | 12 | | emergency department services to insureds, beneficiaries, or | 13 | | enrollees in a participating hospital or participating | 14 | | ambulatory surgical treatment center. | 15 | | (b) When a beneficiary, insured, or enrollee utilizes a | 16 | | participating network hospital or a participating network | 17 | | ambulatory surgery center and, due to any reason, in network | 18 | | services for radiology, anesthesiology, pathology, emergency | 19 | | physician, or neonatology are unavailable and are provided by a | 20 | | nonparticipating facility-based physician or provider, the | 21 | | insurer or health plan shall ensure that the beneficiary, | 22 | | insured, or enrollee shall incur no greater out-of-pocket costs | 23 | | than the beneficiary, insured, or enrollee would have incurred |
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| 1 | | with a participating physician or provider for covered | 2 | | services. | 3 | | (c) If a beneficiary, insured, or enrollee agrees in | 4 | | writing, notwithstanding any other provision of this Code, any | 5 | | benefits a beneficiary, insured, or enrollee receives for | 6 | | services under the situation in subsection (b) are assigned to | 7 | | the nonparticipating facility-based providers. The insurer or | 8 | | health plan shall provide the nonparticipating provider with a | 9 | | written explanation of benefits that specifies the proposed | 10 | | reimbursement and the applicable deductible, copayment or | 11 | | coinsurance amounts owed by the insured, beneficiary or | 12 | | enrollee. The insurer or health plan shall pay any | 13 | | reimbursement directly to the nonparticipating facility-based | 14 | | provider. The nonparticipating facility-based physician or | 15 | | provider shall not bill the beneficiary, insured, or enrollee, | 16 | | except for applicable deductible, copayment, or coinsurance | 17 | | amounts that would apply if the beneficiary, insured, or | 18 | | enrollee utilized a participating physician or provider for | 19 | | covered services. If a beneficiary, insured, or enrollee | 20 | | specifically rejects assignment under this Section in writing | 21 | | to the nonparticipating facility-based provider, then the | 22 | | nonparticipating facility-based provider may bill the | 23 | | beneficiary, insured, or enrollee for the services rendered. | 24 | | (d) For bills assigned under subsection (c), the | 25 | | nonparticipating facility-based provider may bill the insurer | 26 | | or health plan for the services rendered, and the insurer or |
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| 1 | | health plan may pay the billed amount or attempt to negotiate | 2 | | reimbursement with the nonparticipating facility-based | 3 | | provider. If attempts to negotiate reimbursement for services | 4 | | provided by a nonparticipating facility-based provider do not | 5 | | result in a resolution of the payment dispute within 30 days | 6 | | after receipt of written explanation of benefits by the insurer | 7 | | or health plan, then an insurer or health plan or | 8 | | nonparticipating facility-based physician or provider may | 9 | | initiate binding arbitration to determine payment for services | 10 | | provided on a per bill basis. The party requesting arbitration | 11 | | shall notify the other party arbitration has been initiated and | 12 | | state its final offer before arbitration. In response to this | 13 | | notice, the nonrequesting party shall inform the requesting | 14 | | party of its final offer before the arbitration occurs. | 15 | | Arbitration shall be initiated by filing a request with the | 16 | | Department of Insurance. | 17 | | (e) The Department of Insurance shall publish a list of | 18 | | approved arbitrators or entities that shall provide binding | 19 | | arbitration. These arbitrators shall be American Arbitration | 20 | | Association or American Health Lawyers Association trained | 21 | | arbitrators. Both parties must agree on an arbitrator from the | 22 | | Department of Insurance's list of arbitrators. If no agreement | 23 | | can be reached, then a list of 5 arbitrators shall be provided | 24 | | by the Department of Insurance. From the list of 5 arbitrators, | 25 | | the insurer can veto 2 arbitrators and the provider can veto 2 | 26 | | arbitrators. The remaining arbitrator shall be the chosen |
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| 1 | | arbitrator. This arbitration shall consist of a review of the | 2 | | written submissions by both parties. Binding arbitration shall | 3 | | provide for a written decision within 45 days after the request | 4 | | is filed with the Department of Insurance. Both parties shall | 5 | | be bound by the arbitrator's decision. The arbitrator's | 6 | | expenses and fees, together with other expenses, not including | 7 | | attorney's fees, incurred in the conduct of the arbitration, | 8 | | shall be paid as provided in the decision. | 9 | | (f) This Section 356z.3a does not apply to a beneficiary, | 10 | | insured, or enrollee who willfully chooses to access a | 11 | | nonparticipating facility-based physician or provider for | 12 | | health care services available through the insurer's or plan's | 13 | | network of participating physicians and providers. In these | 14 | | circumstances, the contractual requirements for | 15 | | nonparticipating facility-based provider reimbursements will | 16 | | apply. | 17 | | (g) Section 368a of this Act shall not apply during the | 18 | | pendency of a decision under subsection (d) any interest | 19 | | required to be paid a provider under Section 368a shall not | 20 | | accrue until after 30 days of an arbitrator's decision as | 21 | | provided in subsection (d), but in no circumstances longer than | 22 | | 150 days from date the nonparticipating facility-based | 23 | | provider billed for services rendered.
| 24 | | (h) Nothing in this Section shall be interpreted to change | 25 | | the prudent layperson provisions with respect to emergency | 26 | | services under the Managed Care Reform and Patient Rights Act. |
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| 1 | | (Source: P.A. 96-1523, eff. 6-1-11 .)
| 2 | | Section 99. Effective date. This Act takes effect upon | 3 | | becoming law.
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