Public Act 103-0832
 
HB4789 EnrolledLRB103 36280 RPS 66377 b

    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
changing Section 355.4 and by adding Section 355d as follows:
 
    (215 ILCS 5/355.4)
    Sec. 355.4. Provider notification of network plan changes.
    (a) As used in this Section:
    "Contracting entity" means any person or company that
enters into direct contracts with providers for the delivery
of dental services in the ordinary course of business,
including a third-party administrator and a dental carrier.
    "Dental carrier" means a dental insurance company, dental
service corporation, dental plan organization authorized to
provide dental benefits, or a health insurance plan that
includes coverage for dental services.
    (b) No dental carrier may automatically enroll a provider
in a leased network without allowing any provider that is part
of the dental carrier's provider network to choose to not
participate by opting out.
    (c) Any contract entered into or renewed on or after the
effective date of this amendatory Act of the 103rd General
Assembly that allows the rights and obligations of the
contract to be assigned or leased to another insurer shall
provide for notice that informs each provider in writing via
certified mail 60 days before any scheduled assignment or
lease of the network to which the provider is a contracted
provider. To be in compliance with this Section, the
notification must provide the specific URL address where the
following are located: include all contract terms, a policy
manual, a fee schedule, and a statement that the provider has
the right to choose not to participate in third-party access.
The notification must also provide instructions for how the
provider may obtain a copy of those materials.
    (d) A dental carrier that leases or assigns its network
shall not cancel a network participating dentist's contractual
relationship or otherwise penalize a network participating
dentist in any way based on whether or not the dentist accepts
the terms of the assignment or lease. Before accepting the
terms of an assignment or lease agreement as described in this
Section, any provider who receives notification of an
impending assignment or lease must be given the option to
contract directly with the entities proposing to gain access
to the provider's network.
    (e) The provisions of this Section do not apply:
        (1) if access to a provider network contract is
    granted to a dental carrier or an entity operating in
    accordance with the same brand licensee program as the
    contracting entity; or
        (2) to a provider network contract for dental services
    provided to beneficiaries of the State employee group
    health insurance program or the medical assistance program
    under the Illinois Public Aid Code.
(Source: P.A. 103-24, eff. 1-1-24.)
 
    (215 ILCS 5/355d new)
    Sec. 355d. Denials of claims submitted after prior
authorization.
    (a) In this Section:
    "Dental carrier" means an insurer, dental service
corporation, insurance network leasing company, or any company
that offers individual or group policies of accident and
health insurance that provide coverage for dental services.
    "Prior authorization" means any written communication 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 dental carrier.
    (b) Beginning on the effective date of this amendatory Act
of the 103rd General Assembly, a dental carrier shall not 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 carrier 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 dental
        carrier; or
            (D) the person receiving the procedure was not
        eligible for the procedure on the date of service and
        the dental carrier did not know, and with the exercise
        of reasonable care could not have known, that person's
        eligibility status.
    A dental carrier 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 carrier erroneously confirmed
coverage and eligibility, but had sufficient information
available to the dental carrier 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 agreement entered into or amended,
delivered, issued, or renewed on or after the effective date
of this amendatory Act of the 103rd General Assembly that is in
conflict with this Section or that purports to waive any
requirement of this Section is null and void.
 
    Section 10. The Limited Health Service Organization Act is
amended by changing Section 4003 as follows:
 
    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
    Sec. 4003. Illinois Insurance Code provisions. Limited
health service organizations shall be subject to the
provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2,
355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10,
356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
Nothing in this Section shall require a limited health care
plan to cover any service that is not a limited health service.
For purposes of the Illinois Insurance Code, except for
Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
health service organizations in the following categories are
deemed to be domestic companies:
        (1) a corporation under the laws of this State; or
        (2) a corporation organized under the laws of another
    state, 30% or more of the enrollees of which are residents
    of this State, except a corporation subject to
    substantially the same requirements in its state of
    organization as is a domestic company under Article VIII
    1/2 of the Illinois Insurance Code.
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
eff. 1-1-24; revised 8-29-23.)
 
    Section 15. The Voluntary Health Services Plans Act is
amended by changing Section 10 as follows:
 
    (215 ILCS 165/10)  (from Ch. 32, par. 604)
    Sec. 10. Application of Insurance Code provisions. Health
services plan corporations and all persons interested therein
or dealing therewith shall be subject to the provisions of
Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
355d, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,
356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
and (15) of Section 367 of the Illinois Insurance Code.
    Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
103-551, eff. 8-11-23; revised 8-29-23.)

Effective Date: 1/1/2025