HB4789 103RD GENERAL ASSEMBLY

LRB103 36280 RPS 66377 b

103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB4789

Introduced 2/6/2024, by Rep. Bob Morgan

SYNOPSIS AS INTRODUCED:

215 ILCS 5/355d new

Amends the Illinois Insurance Code. Provides that no insurer, dental service plan corporation, insurance network leasing company, or any company that amends, delivers, issues, or renews an individual or group policy of accident and health insurance that provides dental insurance on or after the effective date of the amendatory Act shall deny any claim subsequently submitted for procedures specifically included in a prior authorization unless certain circumstances apply. Provides that a dental service contractor shall not recoup a claim solely due to a loss of coverage for a patient or ineligibility if, at the time of treatment, the dental service contractor erroneously confirmed coverage and eligibility, but had sufficient information available to the dental service contractor indicating that the patient was no longer covered or was ineligible for coverage. Prohibits waiver of the provisions by contract.

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by adding Section 355d as follows:

(215 ILCS 5/355d new)

Sec. 355d. Denials of claims submitted after prior authorization.

(a) As used in this Section, "prior authorization" means any predetermination, prior authorization, or similar authorization that is verifiable, whether through issuance or letter, facsimile, email, or similar means, indicating that a specific procedure is, or multiple procedures are, covered under the patient's dental plan and reimbursable at a specific amount, subject to applicable coinsurance and deductibles, and issued in response to a request submitted by a dentist using a format prescribed by the insurer.

(b) No insurer, dental service plan corporation, insurance network leasing company, or any company that amends, delivers, issues, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 103rd General Assembly that provides dental insurance shall deny any claim subsequently submitted for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:

(1) benefit limitations, such as annual maximums and frequency limitations, that were not applicable at the time of the prior authorization are reached due to utilization after issuance of the prior authorization;

(2) the documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized;

(3) if, after the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary based on the prevailing standard of care;

(4) if, after the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would, at that time, require disapproval pursuant to the terms and conditions for coverage under the plan for the patient in effect at the time the prior authorization was used; or

(5) the claim was denied by a dental service contractor due to one of the following reasons:

(A) another payor is responsible for the payment;

(B) the dentist has already been paid for the procedures identified on the claim;

(C) the claim was submitted fraudulently or the prior authorization was based in whole or material part on erroneous information provided to the insurer, dental service plan corporation, insurance network leasing company, or company that amends, delivers, issues, or renews an individual or group policy of accident and health insurance that provides dental insurance; or

(D) the person receiving the procedure was not eligible for the procedure on the date of service and the dental service contractor did not know, and with the exercise of reasonable care could not have known, that person's eligibility status.

A dental service contractor shall not recoup a claim solely due to a loss of coverage of a patient or ineligibility if, at the time of treatment, the dental service contractor erroneously confirmed coverage and eligibility, but had sufficient information available to the dental service contractor indicating that the patient was no longer covered or was ineligible for coverage.

(c) The provisions of this Section may not be waived by contract. Any contractual arrangement in conflict with the provisions of this Section or that purports to waive any requirement of this Section is null and void.