Illinois · Through at least Public Act 104-790

215 ILCS 220/5: Definitions.

(This Section may contain text from a Public Act with a delayed effective date)
As used in this Act:
"CARC" means Claim Adjustment Reason Codes, which provide the reason for a financial adjustment specific to a particular claim or service referenced in the transmitted Accredited Standards Committee (ASC) X12 835 standard transaction adopted by the United States Department of Health and Human Services under 45 CFR 162.1602.
"Downcoding" means the unilateral alteration by a health care payor of the level of evaluation and management service code or other service code submitted on a claim, resulting in a lower payment. "Downcoding" does not include the practice of addressing instances when providers submit multiple codes for 2 or more services that must be included in one group code pursuant to federal and State program integrity requirements.
"Excepted benefits" has the meaning given to that term in 42 U.S.C. 300gg-91(c) and implementing regulations.
"Group health plan" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.
"Group health plan sponsor" means the plan sponsor of a group health plan.
"Health care payor" means a group health plan sponsor, health insurance issuer, or Medicaid managed care organization.
"Health care professional" means a physician licensed to practice medicine in all its branches under the Medical Practice Act of 1987, a physician assistant licensed under the Physician Assistant Practice Act of 1987, or an advanced practice registered nurse licensed under the Nurse Practice Act.
"Health insurance issuer" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.
"Medicaid managed care organization" has the meaning given to the term "managed care organization" in Section 5H-1 of the Illinois Public Aid Code.
"Plan sponsor" has the meaning given to that term in 29 U.S.C. 1002(16)(B).
"RARC" means Remittance Advice Remark Codes, which provide supplemental information about a financial adjustment indicated by a CARC or information about remittance processing.

Where this section sits in the code

CHAPTER 215 INSURANCE
Transparency in Downcoding Act.

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

As used in this Act:

"CARC" means Claim Adjustment Reason Codes, which provide the reason for a financial adjustment specific to a particular claim or service referenced in the transmitted Accredited Standards Committee (ASC) X12 835 standard transaction adopted by the United States Department of Health and Human Services under 45 CFR 162.1602.

"Downcoding" means the unilateral alteration by a health care payor of the level of evaluation and management service code or other service code submitted on a claim, resulting in a lower payment. "Downcoding" does not include the practice of addressing instances when providers submit multiple codes for 2 or more services that must be included in one group code pursuant to federal and State program integrity requirements.

"Excepted benefits" has the meaning given to that term in 42 U.S.C. 300gg-91(c) and implementing regulations.

"Group health plan" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.

"Group health plan sponsor" means the plan sponsor of a group health plan.

"Health care payor" means a group health plan sponsor, health insurance issuer, or Medicaid managed care organization.

"Health care professional" means a physician licensed to practice medicine in all its branches under the Medical Practice Act of 1987, a physician assistant licensed under the Physician Assistant Practice Act of 1987, or an advanced practice registered nurse licensed under the Nurse Practice Act.

"Health insurance issuer" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.

"Medicaid managed care organization" has the meaning given to the term "managed care organization" in Section 5H-1 of the Illinois Public Aid Code.

"Plan sponsor" has the meaning given to that term in 29 U.S.C. 1002(16)(B).

"RARC" means Remittance Advice Remark Codes, which provide supplemental information about a financial adjustment indicated by a CARC or information about remittance processing.

Collected 2026-09-15T04:46:30Z. Source file · JSON

Browse this collection