ILLINOIS

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The Illinois SBL became effective January 1, 2019. The relevant provisions include:

• What appears to be a 30-day timeline from the date of the EOB to negotiate and once it fails filing the arbitration. There seems to be no time limit stated for filing the arbitration after the 30-day period runs.
• Emergency and inadvertent OON services are both covered by the law.
• Arbitration is before AAA.
• No reimbursement standard is established but you can assume a “reasonableness” standard would apply. The QPA cannot be given preferential treatment above other considerations.

Illinois Insurance Code 215 ILCS 5/356z.22.

According to CMS,

Illinois does not have an applicable All-Payer Model Agreement that would determine the out-of-network rate. Based on the survey response and CMS communications with the Illinois Department of Insurance staff, CMS understands that 215 ILCS 5/356z.3a is a specified state law that will apply for purposes of determining the out-of-network rate with respect to pathology, anesthesiology, neonatology, radiology, or emergency department services furnished to individuals enrolled in preferred provider organization (PPO) coverage in Illinois by nonparticipating providers at participating hospitals and ambulatory surgical treatment centers. The federal independent dispute resolution process under sections 2799A-1(c) and 2799A-2(b) of the PHS Act and 45 CFR 149.510 and 149.520 will apply for purposes of determining the out-of-network rate with respect to any items and services and nonparticipating providers, nonparticipating emergency facilities, and nonparticipating providers of air ambulance services to which 215 ILCS 5/356z.3a does not apply. CMS will enforce the outcome of the federal independent dispute resolution process for such cases in Illinois.

Letter from CMS to Governor of Illinois, dated April 7, 2021.