Illinois § 13.15

§ 13.15.

Billing of insurance carrier. (a) Subject to the restrictions against private insurance use on the basis of material risk of loss of coverage, as determined under Section 13.25, each enrolled provider who is providing a family with early intervention services shall bill the child's insurance carrier for each unit of early intervention service for which coverage may be available. The lead agency may exempt from the requirement of this paragraph any early intervention service that it has deemed not to be covered by insurance plans. When the service is not exempted, providers who receive a denial of payment on the basis that the service is not covered under any circumstance under the plan are not required to bill that carrier for that service again until the following insurance benefit year. That explanation of benefits denying the claim, once submitted to the central billing office, shall be sufficient to meet the requirements of this paragraph as to subsequent services billed under the same billing code provided to that child during that insurance benefit year. Any time limit on a provider's filing of a claim for payment with the central billing office that is imposed through a policy, procedure, or rule of the lead agency shall be suspended until the provider receives an explanation of benefits or other final determination of the claim it files with the child's insurance carrier. (b) In all instances when an insurance carrier has been billed for early intervention services, whether paid in full, paid in part, or denied by the carrier, the provider must provide the central billing office, within 90 days after receipt, with a copy of the explanation of benefits form and other information in the manner prescribed by the lead agency. (c) When the insurance carrier has denied the claim or paid an amount for the early intervention service billed that is less than the current State rate for early intervention services, the provider shall submit the explanation of benefits with a claim for payment, and the lead agency shall pay the provider the difference between the sum actually paid by the insurance carrier for each unit of service provided under the individualized family service plan and the current State rate for early intervention services. The State shall also pay the family's co-payment or co-insurance under its plan, but only to the extent that those payments plus the balance of the claim do not exceed the current State rate for early intervention services. The provider may under no circumstances bill the family for the difference between its charge for services and that which has been paid by the insurance carrier or by the State. (Source: P.A. 97-813, eff. 7-13-12.)