HB4789 EnrolledLRB103 36280 RPS 66377 b HB4789 Enrolled LRB103 36280 RPS 66377 b
HB4789 Enrolled LRB103 36280 RPS 66377 b
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 Illinois Insurance Code is amended by
5 changing Section 355.4 and by adding Section 355d as follows:
6 (215 ILCS 5/355.4)
7 Sec. 355.4. Provider notification of network plan changes.
8 (a) As used in this Section:
9 "Contracting entity" means any person or company that
10 enters into direct contracts with providers for the delivery
11 of dental services in the ordinary course of business,
12 including a third-party administrator and a dental carrier.
13 "Dental carrier" means a dental insurance company, dental
14 service corporation, dental plan organization authorized to
15 provide dental benefits, or a health insurance plan that
16 includes coverage for dental services.
17 (b) No dental carrier may automatically enroll a provider
18 in a leased network without allowing any provider that is part
19 of the dental carrier's provider network to choose to not
20 participate by opting out.
21 (c) Any contract entered into or renewed on or after the
22 effective date of this amendatory Act of the 103rd General
23 Assembly that allows the rights and obligations of the
HB4789 Enrolled LRB103 36280 RPS 66377 b
HB4789 Enrolled- 2 -LRB103 36280 RPS 66377 b HB4789 Enrolled - 2 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 2 - LRB103 36280 RPS 66377 b
1 contract to be assigned or leased to another insurer shall
2 provide for notice that informs each provider in writing via
3 certified mail 60 days before any scheduled assignment or
4 lease of the network to which the provider is a contracted
5 provider. To be in compliance with this Section, the
6 notification must provide the specific URL address where the
7 following are located: include all contract terms, a policy
8 manual, a fee schedule, and a statement that the provider has
9 the right to choose not to participate in third-party access.
10 The notification must also provide instructions for how the
11 provider may obtain a copy of those materials.
12 (d) A dental carrier that leases or assigns its network
13 shall not cancel a network participating dentist's contractual
14 relationship or otherwise penalize a network participating
15 dentist in any way based on whether or not the dentist accepts
16 the terms of the assignment or lease. Before accepting the
17 terms of an assignment or lease agreement as described in this
18 Section, any provider who receives notification of an
19 impending assignment or lease must be given the option to
20 contract directly with the entities proposing to gain access
21 to the provider's network.
22 (e) The provisions of this Section do not apply:
23 (1) if access to a provider network contract is
24 granted to a dental carrier or an entity operating in
25 accordance with the same brand licensee program as the
26 contracting entity; or
HB4789 Enrolled - 2 - LRB103 36280 RPS 66377 b
HB4789 Enrolled- 3 -LRB103 36280 RPS 66377 b HB4789 Enrolled - 3 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 3 - LRB103 36280 RPS 66377 b
1 (2) to a provider network contract for dental services
2 provided to beneficiaries of the State employee group
3 health insurance program or the medical assistance program
4 under the Illinois Public Aid Code.
5 (Source: P.A. 103-24, eff. 1-1-24.)
6 (215 ILCS 5/355d new)
7 Sec. 355d. Denials of claims submitted after prior
8 authorization.
9 (a) In this Section:
10 "Dental carrier" means an insurer, dental service
11 corporation, insurance network leasing company, or any company
12 that offers individual or group policies of accident and
13 health insurance that provide coverage for dental services.
14 "Prior authorization" means any written communication that
15 is verifiable, whether through issuance or letter, facsimile,
16 email, or similar means, indicating that a specific procedure
17 is, or multiple procedures are, covered under the patient's
18 dental plan and reimbursable at a specific amount, subject to
19 applicable coinsurance and deductibles, and issued in response
20 to a request submitted by a dentist using a format prescribed
21 by the dental carrier.
22 (b) Beginning on the effective date of this amendatory Act
23 of the 103rd General Assembly, a dental carrier shall not deny
24 any claim subsequently submitted for procedures specifically
25 included in a prior authorization unless at least one of the
HB4789 Enrolled - 3 - LRB103 36280 RPS 66377 b
HB4789 Enrolled- 4 -LRB103 36280 RPS 66377 b HB4789 Enrolled - 4 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 4 - LRB103 36280 RPS 66377 b
1 following circumstances applies for each procedure denied:
2 (1) benefit limitations, such as annual maximums and
3 frequency limitations, that were not applicable at the
4 time of the prior authorization are reached due to
5 utilization after issuance of the prior authorization;
6 (2) the documentation for the claim provided by the
7 person submitting the claim clearly fails to support the
8 claim as originally authorized;
9 (3) if, after the issuance of the prior authorization,
10 new procedures are provided to the patient or a change in
11 the condition of the patient occurs such that the prior
12 authorized procedure would no longer be considered
13 medically necessary based on the prevailing standard of
14 care;
15 (4) if, after the issuance of the prior authorization,
16 new procedures are provided to the patient or a change in
17 the condition of the patient occurs such that the prior
18 authorized procedure would, at that time, require
19 disapproval pursuant to the terms and conditions for
20 coverage under the plan for the patient in effect at the
21 time the prior authorization was used; or
22 (5) the claim was denied by a dental carrier due to one
23 of the following reasons:
24 (A) another payor is responsible for the payment;
25 (B) the dentist has already been paid for the
26 procedures identified on the claim;
HB4789 Enrolled - 4 - LRB103 36280 RPS 66377 b
HB4789 Enrolled- 5 -LRB103 36280 RPS 66377 b HB4789 Enrolled - 5 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 5 - LRB103 36280 RPS 66377 b
1 (C) the claim was submitted fraudulently or the
2 prior authorization was based in whole or material
3 part on erroneous information provided to the dental
4 carrier; or
5 (D) the person receiving the procedure was not
6 eligible for the procedure on the date of service and
7 the dental carrier did not know, and with the exercise
8 of reasonable care could not have known, that person's
9 eligibility status.
10 A dental carrier shall not recoup a claim solely due to a
11 loss of coverage of a patient or ineligibility if, at the time
12 of treatment, the dental carrier erroneously confirmed
13 coverage and eligibility, but had sufficient information
14 available to the dental carrier indicating that the patient
15 was no longer covered or was ineligible for coverage.
16 (c) The provisions of this Section may not be waived by
17 contract. Any contractual agreement entered into or amended,
18 delivered, issued, or renewed on or after the effective date
19 of this amendatory Act of the 103rd General Assembly that is in
20 conflict with this Section or that purports to waive any
21 requirement of this Section is null and void.
22 Section 10. The Limited Health Service Organization Act is
23 amended by changing Section 4003 as follows:
24 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
HB4789 Enrolled - 5 - LRB103 36280 RPS 66377 b
HB4789 Enrolled- 6 -LRB103 36280 RPS 66377 b HB4789 Enrolled - 6 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 6 - LRB103 36280 RPS 66377 b
1 Sec. 4003. Illinois Insurance Code provisions. Limited
2 health service organizations shall be subject to the
3 provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
4 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
5 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2,
6 355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10,
7 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
8 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
9 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
10 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
11 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
12 XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
13 Nothing in this Section shall require a limited health care
14 plan to cover any service that is not a limited health service.
15 For purposes of the Illinois Insurance Code, except for
16 Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
17 health service organizations in the following categories are
18 deemed to be domestic companies:
19 (1) a corporation under the laws of this State; or
20 (2) a corporation organized under the laws of another
21 state, 30% or more of the enrollees of which are residents
22 of this State, except a corporation subject to
23 substantially the same requirements in its state of
24 organization as is a domestic company under Article VIII
25 1/2 of the Illinois Insurance Code.
26 (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
HB4789 Enrolled - 6 - LRB103 36280 RPS 66377 b
HB4789 Enrolled- 7 -LRB103 36280 RPS 66377 b HB4789 Enrolled - 7 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 7 - LRB103 36280 RPS 66377 b
1 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
2 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
3 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
4 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
5 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
6 eff. 1-1-24; revised 8-29-23.)
7 Section 15. The Voluntary Health Services Plans Act is
8 amended by changing Section 10 as follows:
9 (215 ILCS 165/10) (from Ch. 32, par. 604)
10 Sec. 10. Application of Insurance Code provisions. Health
11 services plan corporations and all persons interested therein
12 or dealing therewith shall be subject to the provisions of
13 Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
14 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
15 355d, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
16 356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
17 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
18 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
19 356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,
20 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
21 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
22 356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
23 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
24 and (15) of Section 367 of the Illinois Insurance Code.
HB4789 Enrolled - 7 - LRB103 36280 RPS 66377 b
HB4789 Enrolled- 8 -LRB103 36280 RPS 66377 b HB4789 Enrolled - 8 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 8 - LRB103 36280 RPS 66377 b
HB4789 Enrolled - 8 - LRB103 36280 RPS 66377 b