093_HB3581
LRB093 03726 JLS 03756 b
1 AN ACT concerning health care benefit claims.
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 368a as follows:
6 (215 ILCS 5/368a)
7 Sec. 368a. Timely payment for health care services.
8 (a) This subsection Section applies to insurers, health
9 maintenance organizations, managed care plans, health care
10 plans, preferred provider organizations, third party
11 administrators, independent practice associations, and
12 physician-hospital organizations (hereinafter referred to as
13 "payors") that provide periodic payments, which are payments
14 not requiring a claim, bill, capitation encounter data, or
15 capitation reconciliation reports, such as prospective
16 capitation payments, to health care professionals and health
17 care facilities to provide medical or health care services
18 for insureds or enrollees.
19 (1) A payor shall make periodic payments in
20 accordance with item (3). Failure to make periodic
21 payments within the period of time specified in item (3)
22 shall entitle the health care professional or health care
23 facility to interest at the rate of 9% per year from the
24 date payment was required to be made to the date of the
25 late payment, provided that any aggregate amount of
26 interest amounting to less than $1 need not be paid. Any
27 required interest payments shall be made within 30 days
28 after the payment.
29 (2) When a payor requires selection of a health
30 care professional or health care facility, the selection
31 shall be completed by the insured or enrollee no later
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1 than 30 days after enrollment. The payor shall provide
2 written notice of this requirement to all insureds and
3 enrollees. Nothing in this Section shall be construed to
4 require a payor to select a health care professional or
5 health care facility for an insured or enrollee.
6 (3) A payor shall provide the health care
7 professional or health care facility with notice of the
8 selection as a health care professional or health care
9 facility by an insured or enrollee and the effective date
10 of the selection within 60 calendar days after the
11 selection. No later than the 60th day following the date
12 an insured or enrollee has selected a health care
13 professional or health care facility or the date that
14 selection becomes effective, whichever is later, or in
15 cases of retrospective enrollment only, 30 days after
16 notice by an employer to the payor of the selection, a
17 payor shall begin periodic payment of the required
18 amounts to the insured's or enrollee's health care
19 professional or health care facility, or the designee of
20 either, calculated from the date of selection or the date
21 the selection becomes effective, whichever is later. All
22 subsequent payments shall be made in accordance with a
23 monthly periodic cycle.
24 (b) Notwithstanding any other provision of this Section,
25 independent practice associations and physician-hospital
26 organizations shall make periodic payment of the required
27 amounts in accordance with a monthly periodic schedule after
28 an insured or enrollee has selected a health care
29 professional or health care facility or after that selection
30 becomes effective, whichever is later.
31 Notwithstanding any other provision of this Section,
32 independent practice associations and physician-hospital
33 organizations shall make all other payments for health
34 services within 30 days after receipt of due proof of loss.
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1 Independent practice associations and physician-hospital
2 organizations shall notify the insured, insured's assignee,
3 health care professional, or health care facility of any
4 failure to provide sufficient documentation for a due proof
5 of loss within 30 days after receipt of the claim for health
6 services.
7 Failure to pay within the required time period shall
8 entitle the payee to interest at the rate of 9% per year from
9 the date the payment is due to the date of the late payment,
10 provided that any aggregate amount of interest amounting to
11 less that $1 need not be paid. Any required interest
12 payments shall be made within 30 days after the payment.
13 (c) All insurers, health maintenance organizations,
14 managed care plans, health care plans, preferred provider
15 organizations, and third party administrators shall ensure
16 that all claims and indemnities concerning health care
17 services other than for any periodic payment shall be paid
18 within 30 days after receipt of due written proof of such
19 loss. An insured, insured's assignee, health care
20 professional, or health care facility shall be notified of
21 any known failure to provide sufficient documentation for a
22 due proof of loss within 30 days after receipt of the claim
23 for health care services. Failure to pay within such period
24 shall entitle the payee to interest at the rate of 9% per
25 year from the 30th day after receipt of such proof of loss to
26 the date of late payment, provided that any aggregate amount
27 of interest amounting to less than one dollar need not be
28 paid. Any required interest payments shall be made within 30
29 days after the payment.
30 (d) The Department shall enforce the provisions of this
31 Section pursuant to the enforcement powers granted to it by
32 law.
33 (e) The Department is hereby granted specific authority
34 to issue a cease and desist order, fine, or otherwise
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1 penalize any entity, including, but not limited to,
2 independent practice associations and physician-hospital
3 organizations, that violates violate this Section. The
4 Department shall adopt reasonable rules to enforce compliance
5 with this Section by all entities including, but not limited
6 to, independent practice associations and physician-hospital
7 organizations.
8 (f) For the purposes of this Section, "due proof of
9 loss" means a clean claim. A claim shall be considered clean
10 when it contains all of the following:
11 (1) The name of the patient.
12 (2) The patient's insurance information, including
13 company name and number.
14 (3) The date service was provided.
15 (4) The professional or provider identification
16 number.
17 (5) Codes for the services provided.
18 (6) The charge for each service code.
19 (g) Medical records are not required for a claim to be
20 considered clean. Medical records may be requested for
21 claims that involve multiple surgical procedures, surgical
22 assistants, and the use of CPT code modifiers. A physician
23 or provider may charge payors the rates set forth in Section
24 8-2003 of the Code of Civil Procedure for requested copies of
25 records.
26 (Source: P.A. 91-605, eff. 12-14-99; 91-788, eff. 6-9-00;
27 92-745, eff. 1-1-03.)
28 Section 99. Effective date. This Act takes effect on
29 December 1, 2003.