Full Text of HB5317 103rd General Assembly
HB5317 103RD GENERAL ASSEMBLY | | | 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. |
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| | A BILL FOR |
| | | | HB5317 | | LRB103 38524 RPS 68660 b |
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| 1 | | AN ACT concerning regulation. | 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly: | 4 | | Section 5. The Uniform Electronic Transactions in Dental | 5 | | Care Billing Act is amended by changing Sections 15, 20, and 25 | 6 | | and by adding Sections 30, 35, 40, and 45 as follows: | 7 | | (215 ILCS 111/15) | 8 | | Sec. 15. Definitions. As used in this Act: | 9 | | "Department" means the Department of Insurance. | 10 | | "Director" means the Director of Insurance. | 11 | | "Dental care provider" means a dentist who bills for | 12 | | services in Illinois. | 13 | | "Dental plan carrier" means an entity subject to the | 14 | | insurance laws and regulations of this State or subject to the | 15 | | jurisdiction of the Director that contracts or offers to | 16 | | contract to provide, deliver, arrange for, pay for, or | 17 | | reimburse any of the costs of dental care services, including | 18 | | an accident and health insurance company, a health maintenance | 19 | | organization, a limited health service organization, a dental | 20 | | service plan corporation, a health services plan corporation, | 21 | | a voluntary health services plan, or any other entity | 22 | | providing a plan of dental insurance, dental benefits, or | 23 | | dental health care services. |
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| 1 | | "Portal" means a website or reasonably similar method of | 2 | | sharing information that (i) is compliant with the federal | 3 | | Health Insurance Portability and Accountability Act of 1996 | 4 | | and the regulations promulgated thereunder, (ii) provides | 5 | | resources and information to dentists and subscribers, and | 6 | | (iii) is compatible with dental software so universal | 7 | | accessibility may be achieved. | 8 | | (Source: P.A. 102-146, eff. 7-23-21.) | 9 | | (215 ILCS 111/20) | 10 | | Sec. 20. Uniform electronic claims and eligibility | 11 | | transactions required. | 12 | | (a) Beginning January 1, 2027 2025 , no dental plan carrier | 13 | | is required to accept from a dental care provider eligibility | 14 | | for a dental plan transaction or dental care claims or | 15 | | equivalent encounter information transaction except as | 16 | | provided in this Act. | 17 | | (b) All dental plan carriers and dental care providers | 18 | | must exchange claims and eligibility information | 19 | | electronically using the standard electronic data interchange | 20 | | transactions for claims submissions, payments, and | 21 | | verification of benefits required under the Health Insurance | 22 | | Portability and Accountability Act in order to be compensable | 23 | | by the dental plan carrier. | 24 | | (Source: P.A. 102-146, eff. 7-23-21.) |
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| 1 | | (215 ILCS 111/25) | 2 | | Sec. 25. Rules; modification of rules. | 3 | | (a) The Department may shall adopt rules as necessary to | 4 | | implement this Act and may establish further exemptions to | 5 | | this Act by rule. | 6 | | (b) A dental plan carrier or dental care provider may not | 7 | | add to or modify the uniform electronic claims and eligibility | 8 | | requirements adopted by the Department. | 9 | | (Source: P.A. 102-146, eff. 7-23-21.) | 10 | | (215 ILCS 111/30 new) | 11 | | Sec. 30. Exemptions. Notwithstanding any other provision | 12 | | of this Act, a dental care provider shall not be required to | 13 | | submit claims electronically under any of the following | 14 | | circumstances: | 15 | | (1) The dental care provider is with a dental practice | 16 | | that, including the dental care provider, employs 4 or | 17 | | fewer full-time or full-time equivalent employees. | 18 | | (2) There is a temporary technological or electrical | 19 | | failure that prevents a claim from being submitted | 20 | | electronically. | 21 | | (3) The dental care provider graduated from a dental | 22 | | school in 1985 or before. | 23 | | (4) The dental care provider graduated from a dental | 24 | | school within 10 years before the effective date of this | 25 | | amendatory Act of the 103rd General Assembly and meets one |
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| 1 | | of the following criteria: | 2 | | (A) The dental care provider started his or her | 3 | | own practice. | 4 | | (B) The dental care provider has purchased a | 5 | | practice that has been previously exempted from the | 6 | | requirements of this Act. | 7 | | (5) The dental care provider demonstrates financial | 8 | | difficulties in buying or managing an electronic claims | 9 | | submission software system. | 10 | | (6) The dental care provider has a disability or | 11 | | medical reason that prohibits the dental care provider | 12 | | from submitting claims electronically. | 13 | | (7) The dental care provider is a temporary dentist | 14 | | operating a practice for another dentist who is | 15 | | temporarily unable to practice. | 16 | | (8) There are other unforeseen practice disruptions, | 17 | | including, but not limited to, natural disasters, physical | 18 | | damage to the practice, or damage to the data system. | 19 | | A dental care provider who is exempted from filing claims | 20 | | electronically under this Section shall file a form with the | 21 | | Department indicating the applicable exemption. The Department | 22 | | shall provide the form no later than January 1, 2027. | 23 | | (215 ILCS 111/35 new) | 24 | | Sec. 35. Eligibility and benefit verification portal. | 25 | | (a) Each dental plan carrier shall establish a portal as |
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| 1 | | described in this Section and shall include information about | 2 | | each type of subscription contract that is sufficient to allow | 3 | | subscribers and dentists to determine the covered services | 4 | | under each subscription contract and the payment or | 5 | | reimbursement amounts for those covered services at the | 6 | | procedure level. The information in the portal shall include | 7 | | the following, as appropriate: | 8 | | (1) Effective date of plan. | 9 | | (2) Status of plan. | 10 | | (3) Termination date of plan. | 11 | | (4) Coordination of benefits; standard or | 12 | | non-duplicating. | 13 | | (5) Claim address. | 14 | | (6) Payer identification. | 15 | | (7) Covered services. | 16 | | (8) Whether a deductible applies and to which | 17 | | services. | 18 | | (9) Remaining deductible: family. | 19 | | (10) Remaining deductible: individual. | 20 | | (11) Preferred in-network co-insurance amount. | 21 | | (12) In-network co-insurance amount. | 22 | | (13) Out-of-network co-insurance amount. | 23 | | (14) Preferred in-network co-payment amount. | 24 | | (15) In-network co-payment amount. | 25 | | (16) Out-of-network co-payment amount. | 26 | | (17) Remaining plan maximum. |
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| 1 | | (18) Remaining lifetime maximum. | 2 | | (19) Last treatment plan payment date applied to the | 3 | | annual maximum or deductible to help determine if a | 4 | | benefit has been used outside of the primary office. | 5 | | (20) Age limitation. | 6 | | (21) Frequency limit by time period. | 7 | | (22) Frequency limit by tooth number. | 8 | | (23) Next available service date based on any | 9 | | frequency limit due to prior treatment history or added | 10 | | custom benefits, such as medical conditions and roll-over. | 11 | | (24) Whether there is a missing tooth clause. | 12 | | (25) Number of quads benefited per visit. | 13 | | (26) Waiting period due to preexisting condition or | 14 | | missing tooth limitation. | 15 | | (27) Prior authorization requirements. | 16 | | (28) Processing policies, such as bundling, | 17 | | downcoding, least expensive alternative treatment | 18 | | requirements, fees disallowed in conjunction with other | 19 | | treatments, and limitations by location. | 20 | | (29) A comprehensive list of all current American | 21 | | Dental Association Codes stating if they are covered, the | 22 | | percentage of coverage, and if there are any conditions | 23 | | that preclude coverage. | 24 | | (b) At minimum, the portal shall provide current and | 25 | | accurate real-time benefit eligibility and benefits | 26 | | information. It is the responsibility of the dental plan |
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| 1 | | carrier to ensure patient eligibility and benefits reporting | 2 | | is timely and accurate. | 3 | | (215 ILCS 111/40 new) | 4 | | Sec. 40. Dental plan carrier requirements. A dental plan | 5 | | carrier must: | 6 | | (1) Provide an electronic portal that is compliant | 7 | | with the federal Health Insurance Portability and | 8 | | Accountability Act of 1996 and the regulations promulgated | 9 | | thereunder and that allows dental care providers to submit | 10 | | claims electronically and directly to dental plan carrier. | 11 | | The portal shall be provided free of charge to the dental | 12 | | care provider. | 13 | | (2) Accept attachments, including, but not limited to, | 14 | | x-rays and other supporting information for claims, in an | 15 | | electronic format with the initial electronic claim's | 16 | | submission and any further submissions thereafter. | 17 | | (3) Provide remittance advice with the corresponding | 18 | | payment that outlines individually per claim: the name of | 19 | | the patient; the date of service; the service code or, if | 20 | | no service code is available, a service description; the | 21 | | amount being paid; the claim number; and other identifying | 22 | | claim information found on an explanation of benefits | 23 | | form. | 24 | | (215 ILCS 111/45 new) |
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| 1 | | Sec. 45. Payment. Nothing in this Act requires a dental | 2 | | care provider to only accept electronic payment from a dental | 3 | | plan carrier. Dental plan carriers shall allow alternative | 4 | | forms of payment, without additional fees or charges, to a | 5 | | dental care provider, if requested. | 6 | | Section 99. Effective date. This Act takes effect upon | 7 | | becoming law. |
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