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| Public Act 102-0632 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by | ||||
changing Section 368d as follows:
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(215 ILCS 5/368d)
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Sec. 368d. Recoupments.
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(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
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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
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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.
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(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
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maintenance organization, independent practice
association, or | ||
physician
hospital
organization that requires a retrospective | ||
reconciliation based upon specific
conditions
outlined in the | ||
contract.
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(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.)
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Section 99. Effective date. This Act takes effect January | ||
1, 2022.
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