SB1974 EnrolledLRB102 12035 BMS 17371 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 368d as follows:
 
6    (215 ILCS 5/368d)
7    Sec. 368d. Recoupments.
8    (a) A health care professional or health care provider
9shall be provided a remittance advice, which must include an
10explanation of a recoupment or offset taken by an insurer,
11health maintenance organization, independent practice
12association, or physician hospital organization, if any. The
13recoupment explanation shall, at a minimum, include the name
14of the patient; the date of service; the service code or if no
15service code is available a service description; the
16recoupment amount; and the reason for the recoupment or
17offset. In addition, an insurer, health maintenance
18organization, independent practice association, or physician
19hospital organization shall provide with the remittance
20advice, or with any demand for recoupment or offset, a
21telephone number or mailing address to initiate an appeal of
22the recoupment or offset together with the deadline for
23initiating an appeal. Such information shall be prominently

 

 

SB1974 Enrolled- 2 -LRB102 12035 BMS 17371 b

1displayed on the remittance advice or written document
2containing the demand for recoupment or offset. Any appeal of
3a recoupment or offset by a health care professional or health
4care provider must be made within 60 days after receipt of the
5remittance advice.
6    (b) It is not a recoupment when a health care professional
7or health care provider is paid an amount prospectively or
8concurrently under a contract with an insurer, health
9maintenance organization, independent practice association, or
10physician hospital organization that requires a retrospective
11reconciliation based upon specific conditions outlined in the
12contract.
13    (c) No recoupment or offset may be requested or withheld
14from future payments 12 18 months or more after the original
15payment is made, except in cases in which:
16        (1) a court, government administrative agency, other
17    tribunal, or independent third-party arbitrator makes or
18    has made a formal finding of fraud or material
19    misrepresentation;
20        (2) an insurer is acting as a plan administrator for
21    the Comprehensive Health Insurance Plan under the
22    Comprehensive Health Insurance Plan Act; or
23        (3) the provider has already been paid in full by any
24    other payer, third party, or workers' compensation
25    insurer; or .
26        (4) an insurer contracted with the Department of

 

 

SB1974 Enrolled- 3 -LRB102 12035 BMS 17371 b

1    Healthcare and Family Services is required by the
2    Department of Healthcare and Family Services to recoup or
3    offset payments due to a federal Medicaid requirement.
4No contract between an insurer and a health care professional
5or health care provider may provide for recoupments in
6violation of this Section. Nothing in this Section shall be
7construed to preclude insurers, health maintenance
8organizations, independent practice associations, or physician
9hospital organizations from resolving coordination of benefits
10between or among each other, including, but not limited to,
11resolution of workers' compensation and third-party liability
12cases, without recouping payment from the provider beyond the
1318-month time limit provided in this subsection (c).
14(Source: P.A. 97-556, eff. 1-1-12.)
 
15    Section 99. Effective date. This Act takes effect January
161, 2022.