215 ILCS 220/15: Prohibition of automatic downcoding.

(This Section may contain text from a Public Act with a delayed effective date)

(a) A health care payor shall not implement any policy or use any algorithm or other automated process, system, or tool that bypasses the evaluation of information included by the billing health care professional to downcode a claim.

(b) A health care payor may use an automated process to identify claims that may justify a downcoding determination following American Medical Association Current Procedural Terminology (CPT) coding guidelines in effect at the time of service. All downcoding determinations must be made or reviewed by a natural person following American Medical Association Current Procedural Terminology (CPT) coding guidelines in effect at the time, and the health care payor must maintain and implement policies and procedures requiring a natural person to consider information included by the billing health care professional on the claim submission in such determination.