215 ILCS 220/30: Dispute process for downcoded claims.

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

(a) A health care payor shall provide health care professionals with a clear and accessible process for disputing downcoded claims, including a written or electronic notice detailing how to initiate a dispute, contact information for the entity or department managing the dispute, reasonable timelines for submission by the billing health care professional of a dispute that are no less than 90 days, and timelines for adjudication of the dispute consistent with applicable State law or regulations governing utilization review.

(b) A health care payor must ensure that all downcoding disputes are reviewed by a natural person. The reviewing natural person must:

(1) be knowledgeable of, and have experience providing, the health care services under dispute;

(2) not have been directly involved in making the decision to downcode the claim;

(3) perform a document review of the clinical information supporting the billed service, including, but not limited to, a review of all pertinent medical records provided to the health care payor and any medical literature provided to the health care payor from the billing health care professional; and

(4) follow American Medical Association Current Procedural Terminology (CPT) coding guidelines in effect at the time of service.

(c) Use of a dispute process for downcoded claims does not preclude the health care professional's or enrollee's right to appeal any adverse determination under applicable State and federal law, rules, or regulations governing utilization review.