HB5317 103RD GENERAL ASSEMBLY

LRB103 38524 RPS 68660 b

103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5317

Introduced 2/9/2024, by Rep. Robert "Bob" Rita

SYNOPSIS AS INTRODUCED:

215 ILCS 111/15
215 ILCS 111/20
215 ILCS 111/25
215 ILCS 111/30 new
215 ILCS 111/35 new
215 ILCS 111/40 new
215 ILCS 111/45 new

Amends the Uniform Electronic Transactions in Dental Care Billing Act. Provides that beginning January 1, 2027 (instead of 2025), no dental plan carrier is required to accept from a dental care provider eligibility for a dental plan transaction or dental care claims or equivalent encounter information transaction. Sets forth exemptions from the requirements of the Act, and requires a dental care provider who is exempt from the requirements of the Act to file a form with the Department of Insurance indicating the applicable exemption. Requires each dental plan carrier to establish a portal that provides certain benefit and billing information. Requires a dental plan carrier to establish an electronic portal that allows dental care providers to submit claims electronically and directly to the dental care provider; accept attachments in an electronic format with the initial electronic claim's submission; and provide remittance advice with the corresponding payment. Provides that nothing in the Act requires a dental care provider to only accept electronic payment from a dental plan carrier. Provides that dental plan carriers shall allow alternative forms of payment, without additional fees or charges, to a dental care provider, if requested. Effective immediately.

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 Uniform Electronic Transactions in Dental Care Billing Act is amended by changing Sections 15, 20, and 25 and by adding Sections 30, 35, 40, and 45 as follows:

(215 ILCS 111/15)

Sec. 15. Definitions. As used in this Act:

"Department" means the Department of Insurance.

"Director" means the Director of Insurance.

"Dental care provider" means a dentist who bills for services in Illinois.

"Dental plan carrier" means an entity subject to the insurance laws and regulations of this State or subject to the jurisdiction of the Director that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of dental care services, including an accident and health insurance company, a health maintenance organization, a limited health service organization, a dental service plan corporation, a health services plan corporation, a voluntary health services plan, or any other entity providing a plan of dental insurance, dental benefits, or dental health care services.

"Portal" means a website or reasonably similar method of sharing information that (i) is compliant with the federal Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder, (ii) provides resources and information to dentists and subscribers, and (iii) is compatible with dental software so universal accessibility may be achieved.

(Source: P.A. 102-146, eff. 7-23-21.)

(215 ILCS 111/20)

Sec. 20. Uniform electronic claims and eligibility transactions required.

(a) Beginning January 1, 2027 2025, no dental plan carrier is required to accept from a dental care provider eligibility for a dental plan transaction or dental care claims or equivalent encounter information transaction except as provided in this Act.

(b) All dental plan carriers and dental care providers must exchange claims and eligibility information electronically using the standard electronic data interchange transactions for claims submissions, payments, and verification of benefits required under the Health Insurance Portability and Accountability Act in order to be compensable by the dental plan carrier.

(Source: P.A. 102-146, eff. 7-23-21.)

(215 ILCS 111/25)

Sec. 25. Rules; modification of rules.

(a) The Department may shall adopt rules as necessary to implement this Act and may establish further exemptions to this Act by rule.

(b) A dental plan carrier or dental care provider may not add to or modify the uniform electronic claims and eligibility requirements adopted by the Department.

(Source: P.A. 102-146, eff. 7-23-21.)

(215 ILCS 111/30 new)

Sec. 30. Exemptions. Notwithstanding any other provision of this Act, a dental care provider shall not be required to submit claims electronically under any of the following circumstances:

(1) The dental care provider is with a dental practice that, including the dental care provider, employs 4 or fewer full-time or full-time equivalent employees.

(2) There is a temporary technological or electrical failure that prevents a claim from being submitted electronically.

(3) The dental care provider graduated from a dental school in 1985 or before.

(4) The dental care provider graduated from a dental school within 10 years before the effective date of this amendatory Act of the 103rd General Assembly and meets one of the following criteria:

(A) The dental care provider started his or her own practice.

(B) The dental care provider has purchased a practice that has been previously exempted from the requirements of this Act.

(5) The dental care provider demonstrates financial difficulties in buying or managing an electronic claims submission software system.

(6) The dental care provider has a disability or medical reason that prohibits the dental care provider from submitting claims electronically.

(7) The dental care provider is a temporary dentist operating a practice for another dentist who is temporarily unable to practice.

(8) There are other unforeseen practice disruptions, including, but not limited to, natural disasters, physical damage to the practice, or damage to the data system.

A dental care provider who is exempted from filing claims electronically under this Section shall file a form with the Department indicating the applicable exemption. The Department shall provide the form no later than January 1, 2027.

(215 ILCS 111/35 new)

Sec. 35. Eligibility and benefit verification portal.

(a) Each dental plan carrier shall establish a portal as described in this Section and shall include information about each type of subscription contract that is sufficient to allow subscribers and dentists to determine the covered services under each subscription contract and the payment or reimbursement amounts for those covered services at the procedure level. The information in the portal shall include the following, as appropriate:

(1) Effective date of plan.

(2) Status of plan.

(3) Termination date of plan.

(4) Coordination of benefits; standard or non-duplicating.

(5) Claim address.

(6) Payer identification.

(7) Covered services.

(8) Whether a deductible applies and to which services.

(9) Remaining deductible: family.

(10) Remaining deductible: individual.

(11) Preferred in-network co-insurance amount.

(12) In-network co-insurance amount.

(13) Out-of-network co-insurance amount.

(14) Preferred in-network co-payment amount.

(15) In-network co-payment amount.

(16) Out-of-network co-payment amount.

(17) Remaining plan maximum.

(18) Remaining lifetime maximum.

(19) Last treatment plan payment date applied to the annual maximum or deductible to help determine if a benefit has been used outside of the primary office.

(20) Age limitation.

(21) Frequency limit by time period.

(22) Frequency limit by tooth number.

(23) Next available service date based on any frequency limit due to prior treatment history or added custom benefits, such as medical conditions and roll-over.

(24) Whether there is a missing tooth clause.

(25) Number of quads benefited per visit.

(26) Waiting period due to preexisting condition or missing tooth limitation.

(27) Prior authorization requirements.

(28) Processing policies, such as bundling, downcoding, least expensive alternative treatment requirements, fees disallowed in conjunction with other treatments, and limitations by location.

(29) A comprehensive list of all current American Dental Association Codes stating if they are covered, the percentage of coverage, and if there are any conditions that preclude coverage.

(b) At minimum, the portal shall provide current and accurate real-time benefit eligibility and benefits information. It is the responsibility of the dental plan carrier to ensure patient eligibility and benefits reporting is timely and accurate.

(215 ILCS 111/40 new)

Sec. 40. Dental plan carrier requirements. A dental plan carrier must:

(1) Provide an electronic portal that is compliant with the federal Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder and that allows dental care providers to submit claims electronically and directly to dental plan carrier. The portal shall be provided free of charge to the dental care provider.

(2) Accept attachments, including, but not limited to, x-rays and other supporting information for claims, in an electronic format with the initial electronic claim's submission and any further submissions thereafter.

(3) Provide remittance advice with the corresponding payment that outlines individually per claim: the name of the patient; the date of service; the service code or, if no service code is available, a service description; the amount being paid; the claim number; and other identifying claim information found on an explanation of benefits form.

(215 ILCS 111/45 new)

Sec. 45. Payment. Nothing in this Act requires a dental care provider to only accept electronic payment from a dental plan carrier. Dental plan carriers shall allow alternative forms of payment, without additional fees or charges, to a dental care provider, if requested.

Section 99. Effective date. This Act takes effect upon becoming law.