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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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