HB4113 94TH GENERAL ASSEMBLY

LRB094 13983 LJB 48864 b

94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB4113

Introduced 09/20/05, by Rep. William B. Black

SYNOPSIS AS INTRODUCED:

215 ILCS 5/368c
215 ILCS 5/368f new

Amends the Illinois Insurance Code. Requires health insurers to provide certain information to the insured and the health care professional or provider when prospectively denying or certifying medical care. Makes other changes.

A BILL FOR

AN ACT concerning insurance.

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 368c and by adding Section 368f as follows:

(215 ILCS 5/368c)

Sec. 368c. Remittance advice and procedures.

(a) A remittance advice shall be furnished to a health care professional or health care provider that identifies the disposition of each claim. The remittance advice shall identify the services billed; the patient responsibility, if any; the actual payment, if any, for the services billed; and the reason for any reduction to the amount for which the claim was submitted. For any reductions to the amount for which the claim was submitted, the remittance shall identify any withholds and the reason for any denial or reduction.

A remittance advice for capitation or prospective payment arrangements shall be furnished to a health care professional or health care provider pursuant to a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization in accordance with the terms of the contract.

(b) When health care services are provided by a non-participating health care professional or health care provider, an insurer, health maintenance organization, independent practice association, or physician hospital organization may pay for covered services either to a patient directly or to the non-participating health care professional or health care provider.

(c) When a person presents a benefits information card to a health care professional or health care provider, the a health care professional or health care provider shall make a good faith effort to inform the person if the health care professional or health care provider has a participation contract with the insurer, health maintenance organization, or other entity identified on the card.

(Source: P.A. 93-261, eff. 1-1-04.)

(215 ILCS 5/368f new)

Sec. 368f. Prospective denial and certification of coverage.

(a) An insurer that prospectively denies coverage for medical treatment shall provide to the insured and the health care professional or health care provider a statement of the reasons for the denial, including, but not limited to, that the medical care is not covered under the insured's contract with the insurer or the professional or provider is not contracted with the insurer or is out-of-network. If the basis for denial is that the professional or provider is not contracted with the insurer, the insurer shall provide the insured with a list of professionals and providers that are contracted with the insurer or are in-network in the geographic area within which the insured is seeking treatment.

(b) An insurer that prospectively certifies coverage for medical treatment shall provide the insured and the health care professional or health care provider with a statement providing details of coverage, including, but not limited to, what is covered under the insured's contract with the insurer, the rate or percentage at which the insurer will reimburse the professional or provider for the services, and the professionals and providers that are considered in-network by the insurer in the geographic area in which the insured is seeking treatment.

(c) As used in this Section, "insurer" means a health insurer, health maintenance organization, independent practice association, physician hospital organization, preferred provider organization, or any other organization that provides or arranges for one or more health care plans under a system that causes any part of the risk of health care delivery to be borne by the organization or its providers.