§ 143.31 — Uniform medical claim and billing forms

Illinois § 143.31

• Jurisdiction: Illinois
• Topic: REGULATION
• Ch. 215: INSURANCE
• Act 215 ILCS 5/: Illinois Insurance Code.
• Art.: Article IX - Provisions Applicable To All Companies

Text

(a) The Director shall prescribe by rule, after consultation with providers of health care or treatment, insurers, hospital, medical, and dental service corporations, and other prepayment organizations, insurance claim and billing forms that the Director determines will provide for uniformity and simplicity in insurance claims handling. The claim forms shall include, but need not be limited to, information regarding the medical diagnosis, treatment, and prognosis of the patient, together with the details of charges incident to the providing of care, treatment, or services, sufficient for the purpose of meeting the proof requirements of an insurance policy or a hospital, medical, or dental service contract. (b) An insurer or a provider of health care treatment may not refuse to accept a claim or bill submitted on duly promulgated uniform claim and billing forms. An insurer, however, may accept claims and bills submitted on any other form. (c) After receipt and adjudication or readjudication of any claim or bill with all required documentation from an insured or provider, or a notification under 42 U.S.C. 300gg-136, an accident and health insurer shall send explanation of benefits paid statements or claims summary statements to an insured in a format and written in a manner that promotes understanding by the insured by setting forth all of the following: (1) The total dollar amount submitted to the insurer for payment. (2) Any reduction in the amount paid due to the application of any co-payment, coinsurance, or deductible, along with an explanation of the amount of the co-payment, coinsurance, or deductible applied under the insured's policy. (3) Any reduction in the amount paid due to the application of any other policy limitation, penalty, or exclusion set forth in the insured's policy, along with an explanation thereof. (4) The total dollar amount paid. (5) The total dollar amount remaining unpaid. (6) If applicable under 42 U.S.C. 300gg-111 or 42 U.S.C. 300gg-115, other information required for any explanation of benefits described in either of those Sections. (d) The Director may issue an order directing an accident and health insurer to comply with subsection (c). (e) An accident and health insurer does not violate subsection (c) by using a document that the accident and health insurer is required to use by the federal government or the State. (f) The adoption of uniform claim forms and uniform billing forms by the Director under this Section does not preclude an insurer, hospital, medical, or dental service corporation, or other prepayment organization from obtaining any necessary additional information regarding a claim from the claimant, provider of health care or treatment, or certifier of coverage, as may be required. (g) On and after January 1, 1996 when billing insurers or otherwise filing insurance claims with insurers subject to this Section, providers of health care or treatment, medical services, dental services, pharmaceutical services, or medical equipment must use the uniform claim and billing forms adopted by the Director under this Section.

Legislative History

(Source: P.A. 103-656, eff. 1-1-25 .)