SB3233 EngrossedLRB097 19652 RPM 64906 b

1    AN ACT concerning insurance.
 
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 356z.3a as follows:
 
6    (215 ILCS 5/356z.3a)
7    Sec. 356z.3a. Nonparticipating facility-based physicians
8and providers.
9    (a) For purposes of this Section, "facility-based
10provider" means a physician or other provider who provide
11radiology, anesthesiology, pathology, neonatology, or
12emergency department services to insureds, beneficiaries, or
13enrollees in a participating hospital or participating
14ambulatory surgical treatment center.
15    (b) When a beneficiary, insured, or enrollee utilizes a
16participating network hospital or a participating network
17ambulatory surgery center and, due to any reason, in network
18services for radiology, anesthesiology, pathology, emergency
19physician, or neonatology are unavailable and are provided by a
20nonparticipating facility-based physician or provider, the
21insurer or health plan shall ensure that the beneficiary,
22insured, or enrollee shall incur no greater out-of-pocket costs
23than the beneficiary, insured, or enrollee would have incurred

 

 

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1with a participating physician or provider for covered
2services.
3    (c) If a beneficiary, insured, or enrollee agrees in
4writing, notwithstanding any other provision of this Code, any
5benefits a beneficiary, insured, or enrollee receives for
6services under the situation in subsection (b) are assigned to
7the nonparticipating facility-based providers. The insurer or
8health plan shall provide the nonparticipating provider with a
9written explanation of benefits that specifies the proposed
10reimbursement and the applicable deductible, copayment or
11coinsurance amounts owed by the insured, beneficiary or
12enrollee. The insurer or health plan shall pay any
13reimbursement directly to the nonparticipating facility-based
14provider. The nonparticipating facility-based physician or
15provider shall not bill the beneficiary, insured, or enrollee,
16except for applicable deductible, copayment, or coinsurance
17amounts that would apply if the beneficiary, insured, or
18enrollee utilized a participating physician or provider for
19covered services. If a beneficiary, insured, or enrollee
20specifically rejects assignment under this Section in writing
21to the nonparticipating facility-based provider, then the
22nonparticipating facility-based provider may bill the
23beneficiary, insured, or enrollee for the services rendered.
24    (d) For bills assigned under subsection (c), the
25nonparticipating facility-based provider may bill the insurer
26or health plan for the services rendered, and the insurer or

 

 

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1health plan may pay the billed amount or attempt to negotiate
2reimbursement with the nonparticipating facility-based
3provider. If attempts to negotiate reimbursement for services
4provided by a nonparticipating facility-based provider do not
5result in a resolution of the payment dispute within 30 days
6after receipt of written explanation of benefits by the insurer
7or health plan, then an insurer or health plan or
8nonparticipating facility-based physician or provider may
9initiate binding arbitration to determine payment for services
10provided on a per bill basis. The party requesting arbitration
11shall notify the other party arbitration has been initiated and
12state its final offer before arbitration. In response to this
13notice, the nonrequesting party shall inform the requesting
14party of its final offer before the arbitration occurs.
15Arbitration shall be initiated by filing a request with the
16Department of Insurance.
17    (e) The Department of Insurance shall publish a list of
18approved arbitrators or entities that shall provide binding
19arbitration. These arbitrators shall be American Arbitration
20Association or American Health Lawyers Association trained
21arbitrators. Both parties must agree on an arbitrator from the
22Department of Insurance's list of arbitrators. If no agreement
23can be reached, then a list of 5 arbitrators shall be provided
24by the Department of Insurance. From the list of 5 arbitrators,
25the insurer can veto 2 arbitrators and the provider can veto 2
26arbitrators. The remaining arbitrator shall be the chosen

 

 

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1arbitrator. This arbitration shall consist of a review of the
2written submissions by both parties. Binding arbitration shall
3provide for a written decision within 45 days after the request
4is filed with the Department of Insurance. Both parties shall
5be bound by the arbitrator's decision. The arbitrator's
6expenses and fees, together with other expenses, not including
7attorney's fees, incurred in the conduct of the arbitration,
8shall be paid as provided in the decision.
9    (f) This Section 356z.3a does not apply to a beneficiary,
10insured, or enrollee who willfully chooses to access a
11nonparticipating facility-based physician or provider for
12health care services available through the insurer's or plan's
13network of participating physicians and providers. In these
14circumstances, the contractual requirements for
15nonparticipating facility-based provider reimbursements will
16apply.
17    (g) Section 368a of this Act shall not apply during the
18pendency of a decision under subsection (d) any interest
19required to be paid a provider under Section 368a shall not
20accrue until after 30 days of an arbitrator's decision as
21provided in subsection (d), but in no circumstances longer than
22150 days from date the nonparticipating facility-based
23provider billed for services rendered.
24    (h) Nothing in this Section shall be interpreted to change
25the prudent layperson provisions with respect to emergency
26services under the Managed Care Reform and Patient Rights Act.

 

 

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1(Source: P.A. 96-1523, eff. 6-1-11.)
 
2    Section 99. Effective date. This Act takes effect upon
3becoming law.