Illinois SB 3114: $DOL OCE

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SB3114 EnrolledLRB104 19668 BAB 33117 b

1 AN ACT concerning regulation.

2 Be it enacted by the People of the State of Illinois, 

3represented in the General Assembly:

4 Section 1. Short title. This Act may be cited as the 

5Transparency in Downcoding Act.

6 Section 2. Findings. The General Assembly finds that:

7 (1) Downcoding of medical claims, when done without 

8 clear justification or transparency, undermines fair 

9 payment of health care professionals and threatens the 

10 stability of medical practices.

11 (2) Improper downcoding may result in harm to patients 

12 by disincentivizing care for individuals with complex 

13 medical conditions.

14 (3) It is in the public interest to ensure that all 

15 coding adjustments are clinically supported, transparent, 

16 appealable, and free from discriminatory targeting.

17 Section 5. Definitions. As used in this Act:

18 "CARC" means Claim Adjustment Reason Codes, which provide 

19the reason for a financial adjustment specific to a particular 

20claim or service referenced in the transmitted Accredited 

21Standards Committee (ASC) X12 835 standard transaction adopted 

22by the United States Department of Health and Human Services 

SB3114 Enrolled- 2 -LRB104 19668 BAB 33117 b

1under 45 CFR 162.1602.

2 "Downcoding" means the unilateral alteration by a health 

3care payor of the level of evaluation and management service 

4code or other service code submitted on a claim, resulting in a 

5lower payment. "Downcoding" does not include the practice of 

6addressing instances when providers submit m