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(325 ILCS 20/13.15)
Sec. 13.15. Billing of insurance carrier.
(a) Subject to the restrictions against
private
insurance use on the basis of material risk of
loss of
coverage, as determined under Section 13.25, each
enrolled
provider who is providing a family with early
intervention
services shall bill the child's insurance carrier for
each
unit
of early intervention service for
which coverage may be
available. The lead agency may exempt from the
requirement of this paragraph any early intervention service
that it has deemed not to be covered by insurance plans.
When the service is not exempted, providers who
receive a denial of payment on the basis that the service is
not covered under any circumstance under the plan are not
required to bill that carrier for that service again until the following
insurance benefit year. That
explanation of benefits denying the claim, once submitted to
the central billing office, shall be sufficient to meet the
requirements of this paragraph as to subsequent services billed under the same
billing code provided to that child during that insurance benefit year. Any
time limit on a
provider's filing of a claim for payment with the central
billing office that is
imposed through a
policy, procedure, or rule of the lead agency shall be
suspended
until the provider receives an explanation of
benefits or
other final determination of the claim it files
with the
child's insurance carrier.
(b) In all instances when an insurance carrier has
been billed for early intervention services, whether paid in
full, paid in part, or denied by the carrier, the provider must
provide the central billing office, within 90 days after receipt, with a copy
of the explanation
of benefits form and other information in the manner prescribed by the lead
agency.
(c) When the insurance carrier has denied the
claim or paid an amount for the early intervention service
billed that is less than the current State rate for early
intervention services, the provider shall submit the
explanation of benefits with a claim for payment, and the lead
agency shall pay the provider the difference between the sum
actually paid by the insurance carrier for each unit of service
provided under the individualized family service plan and
the current State rate for early intervention services.
The State shall also pay the family's co-payment or co-insurance under its
plan, but only to the extent that those
payments plus the balance of the claim do not exceed the
current State rate for early intervention services. The
provider may under no circumstances bill the family for the
difference between its charge for services and that which
has been paid by the insurance carrier or by the State.
(Source: P.A. 97-813, eff. 7-13-12.)
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