Bill Text: IL HB1193 | 2011-2012 | 97th General Assembly | Chaptered
Bill Title: Amends the Illinois Insurance Code. In the provision concerning recoupment, provides that no recoupment or offset may be requested or withheld from future payments 366 or more days after the original payment. Provides for exceptions for cases in which there has been a formal adjudication of fraud or the provider has already been paid in full. Provides that nothing in the provision concerning recoupments shall be construed to preclude insurers or certain organizations from resolving coordination of benefits between or among each other without recouping payment from the provider beyond the 366-day time limit.
Spectrum: Partisan Bill (Democrat 9-0)
Status: (Passed) 2011-08-25 - Public Act . . . . . . . . . 97-0556 [HB1193 Detail]
Download: Illinois-2011-HB1193-Chaptered.html
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Public Act 097-0556 | ||||
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AN ACT concerning insurance.
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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
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
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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.
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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 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. | ||
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. 93-261, eff. 1-1-04.)
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