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Public Act 102-0632


 

Public Act 0632 102ND GENERAL ASSEMBLY

  
  
  

 


 
Public Act 102-0632
 
SB1974 EnrolledLRB102 12035 BMS 17371 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
changing Section 368d as follows:
 
    (215 ILCS 5/368d)
    Sec. 368d. Recoupments.
    (a) A health care professional or health care provider
shall be provided a remittance advice, which must include an
explanation of a recoupment or offset taken by an insurer,
health maintenance organization, independent practice
association, or physician hospital organization, if any. The
recoupment explanation shall, at a minimum, include the name
of the patient; the date of service; the service code or if no
service code is available a service description; the
recoupment amount; and the reason for the recoupment or
offset. In addition, an insurer, health maintenance
organization, independent practice association, or physician
hospital organization shall provide with the remittance
advice, or with any demand for recoupment or offset, a
telephone number or mailing address to initiate an appeal of
the recoupment or offset together with the deadline for
initiating an appeal. Such information shall be prominently
displayed on the remittance advice or written document
containing the demand for recoupment or offset. Any appeal of
a recoupment or offset by a health care professional or health
care provider must be made within 60 days after receipt of the
remittance advice.
    (b) It is not a recoupment when a health care professional
or health care provider is paid an amount prospectively or
concurrently under a contract with an insurer, health
maintenance organization, independent practice association, or
physician hospital organization that requires a retrospective
reconciliation based upon specific conditions outlined in the
contract.
    (c) No recoupment or offset may be requested or withheld
from future payments 12 18 months or more after the original
payment is made, except in cases in which:
        (1) a court, government administrative agency, other
    tribunal, or independent third-party arbitrator makes or
    has made a formal finding of fraud or material
    misrepresentation;
        (2) an insurer is acting as a plan administrator for
    the Comprehensive Health Insurance Plan under the
    Comprehensive Health Insurance Plan Act; or
        (3) the provider has already been paid in full by any
    other payer, third party, or workers' compensation
    insurer; or .
        (4) an insurer contracted with the Department of
    Healthcare and Family Services is required by the
    Department of Healthcare and Family Services to recoup or
    offset payments due to a federal Medicaid requirement.
No contract between an insurer and a health care professional
or health care provider may provide for recoupments in
violation of this Section. Nothing in this Section shall be
construed to preclude insurers, health maintenance
organizations, independent practice associations, or physician
hospital organizations from resolving coordination of benefits
between or among each other, including, but not limited to,
resolution of workers' compensation and third-party liability
cases, without recouping payment from the provider beyond the
18-month time limit provided in this subsection (c).
(Source: P.A. 97-556, eff. 1-1-12.)
 
    Section 99. Effective date. This Act takes effect January
1, 2022.

Effective Date: 1/1/2022