HB1864 EngrossedLRB104 06097 BAB 16130 b HB1864 Engrossed LRB104 06097 BAB 16130 b
HB1864 Engrossed LRB104 06097 BAB 16130 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 Uniform Electronic Transactions in Dental
5 Care Billing Act is amended by changing Sections 5, 15, 20, and
6 25 and by adding Sections 30, 35, and 40 as follows:
7 (215 ILCS 111/5)
8 Sec. 5. Purpose. The purpose of this Act is to standardize
9 the forms used in the billing and reimbursement of dental
10 care, reduce the number of forms used, increase efficiency in
11 the reimbursement of dental care through standardization, and
12 encourage the use of and prescribe a timetable for
13 implementation of a secure electronic data interchange of
14 dental care expenses and reimbursement.
15 (Source: P.A. 102-146, eff. 7-23-21.)
16 (215 ILCS 111/15)
17 Sec. 15. Definitions. As used in this Act:
18 "Department" means the Department of Insurance.
19 "Director" means the Director of Insurance.
20 "Dental care provider" means a dentist who bills for
21 services in Illinois.
22 "Dental plan carrier" means an entity subject to the
HB1864 Engrossed LRB104 06097 BAB 16130 b
HB1864 Engrossed- 2 -LRB104 06097 BAB 16130 b HB1864 Engrossed - 2 - LRB104 06097 BAB 16130 b
HB1864 Engrossed - 2 - LRB104 06097 BAB 16130 b
1 insurance laws and regulations of this State or subject to the
2 jurisdiction of the Director that contracts or offers to
3 contract to provide, deliver, arrange for, pay for, or
4 reimburse any of the costs of dental care services, including
5 an accident and health insurance company, a health maintenance
6 organization, a limited health service organization, a dental
7 service plan corporation, a health services plan corporation,
8 a voluntary health services plan, or any other entity
9 providing a plan of dental insurance, dental benefits, or
10 dental health care services.
11 "Portal" means a website or reasonably similar method of
12 sharing information that: (i) is compliant with the federal
13 Health Insurance Portability and Accountability Act of 1996
14 and the regulations promulgated thereunder, and (ii) provides
15 resources and information to dental care providers and
16 subscribers.
17 (Source: P.A. 102-146, eff. 7-23-21.)
18 (215 ILCS 111/20)
19 Sec. 20. Uniform electronic claims and eligibility
20 transactions required.
21 (a) Beginning January 1, 2027 2026, no dental plan carrier
22 is required to accept from a dental care provider eligibility
23 for a dental plan transaction or dental care claims or
24 equivalent encounter information transaction except as
25 provided in this Act.
HB1864 Engrossed - 2 - LRB104 06097 BAB 16130 b
HB1864 Engrossed- 3 -LRB104 06097 BAB 16130 b HB1864 Engrossed - 3 - LRB104 06097 BAB 16130 b
HB1864 Engrossed - 3 - LRB104 06097 BAB 16130 b
1 (b) All dental plan carriers and dental care providers
2 must exchange claims and eligibility information
3 electronically using the standard electronic data interchange
4 transactions for claims submissions, payments, and
5 verification of benefits required under the Health Insurance
6 Portability and Accountability Act in order to be compensable
7 by the dental plan carrier.
8 (c) All dental plan carriers and dental care providers
9 must comply with applicable State and federal privacy and
10 security laws, and regulations when conducting the exchange of
11 information under this Act.
12 (Source: P.A. 102-146, eff. 7-23-21; 103-705, eff. 7-19-24.)
13 (215 ILCS 111/25)
14 Sec. 25. Rules; modification of rules.
15 (a) The Department may shall adopt rules as necessary to
16 implement this Act and may establish further exemptions to
17 this Act by rule.
18 (b) A dental plan carrier or dental care provider may not
19 add to or modify the uniform electronic claims and eligibility
20 requirements adopted by the Department.
21 (Source: P.A. 102-146, eff. 7-23-21.)
22 (215 ILCS 111/30 new)
23 Sec. 30. Exemptions.
24 (a) Notwithstanding any other provision of this Act, a
HB1864 Engrossed - 3 - LRB104 06097 BAB 16130 b
HB1864 Engrossed- 4 -LRB104 06097 BAB 16130 b HB1864 Engrossed - 4 - LRB104 06097 BAB 16130 b
HB1864 Engrossed - 4 - LRB104 06097 BAB 16130 b
1 dental care provider shall not be required to submit claims
2 electronically under any of the following circumstances:
3 (1) There is a temporary technological event, due to
4 unforeseen practice disruptions, including, but not
5 limited to, natural disasters, physical damage to the
6 practice, or damage to the data system that prevents a
7 claim from being submitted electronically for more than 14
8 days.
9 (2) The dental care provider plans to retire prior to
10 January 1, 2031.
11 (3) A dental care provider works less than 20 hours
12 per week and is a solo practitioner.
13 (4) The dental care provider is a dental care provider
14 who is temporarily operating a practice for another dental
15 care provider who is unable to practice.
16 (b) A dental care provider who is exempted from filing
17 claims electronically under this Section shall file a form
18 with the Department indicating the applicable exemption. The
19 Department shall provide the form no later than January 1,
20 2027.
21 (c) Any dental care provider that starts a dental care
22 practice or purchases a practice and who was previously
23 exempted from the requirements of this Act shall have 2 years
24 from the date the practice is started or purchased to comply
25 with this Act.
HB1864 Engrossed - 4 - LRB104 06097 BAB 16130 b
HB1864 Engrossed- 5 -LRB104 06097 BAB 16130 b HB1864 Engrossed - 5 - LRB104 06097 BAB 16130 b
HB1864 Engrossed - 5 - LRB104 06097 BAB 16130 b
1 (215 ILCS 111/35 new)
2 Sec. 35. Eligibility and benefit verification portal.
3 (a) Each dental plan carrier shall establish a portal as
4 described in this Section and shall include information about
5 each type of subscription contract that is sufficient to allow
6 subscribers and dental care providers to determine the covered
7 services under each subscription contract and the payment or
8 reimbursement amounts for those covered services at the
9 procedure level. The information in the portal shall include
10 the following, as appropriate:
11 (1) Effective date of plan.
12 (2) Termination date of plan.
13 (3) Coordination of benefits; standard or
14 non-duplicating.
15 (4) Claim address.
16 (5) Payer identification.
17 (6) Covered services.
18 (7) Whether a deductible applies and to which
19 services.
20 (8) Remaining deductible: family.
21 (9) Remaining deductible: individual.
22 (10) In-network coinsurance percentage.
23 (11) Out-of-network coinsurance percentage.
24 (12) Remaining plan maximum.
25 (13) Remaining lifetime maximum, if applicable.
26 (14) Previous 12 months of claim payments applied to
HB1864 Engrossed - 5 - LRB104 06097 BAB 16130 b
HB1864 Engrossed- 6 -LRB104 06097 BAB 16130 b HB1864 Engrossed - 6 - LRB104 06097 BAB 16130 b
HB1864 Engrossed - 6 - LRB104 06097 BAB 16130 b
1 the member's annual maximum or deductible to help
2 determine if a benefit has been used outside of the
3 primary office.
4 (15) Age limitation.
5 (16) Frequency limit by time period.
6 (17) Frequency limit by tooth number.
7 (18) Next available service date or previous service
8 dates based on any frequency limit due to prior treatment
9 history or added custom benefits, such as medical
10 conditions and roll-over.
11 (19) Number of quads benefited per visit if a specific
12 benefit limitation exists that may limit the number of
13 quads treated and services rendered per visit.
14 (20) Waiting period due to preexisting condition or
15 missing tooth limitation.
16 (21) Prior authorization requirements.
17 (22) A comprehensive list (or procedure code level
18 lookup tool) of all current American Dental Association
19 CDT Codes stating if they are covered, the percentage of
20 coverage, and if there are any conditions that preclude
21 coverage.
22 (b) At minimum, the portal shall provide current and
23 accurate real-time benefit eligibility and benefits
24 information. It is the responsibility of the dental plan
25 carrier to ensure patient eligibility and benefits reporting
26 is timely and accurate.
HB1864 Engrossed - 6 - LRB104 06097 BAB 16130 b
HB1864 Engrossed- 7 -LRB104 06097 BAB 16130 b HB1864 Engrossed - 7 - LRB104 06097 BAB 16130 b
HB1864 Engrossed - 7 - LRB104 06097 BAB 16130 b
1 (c) A dental plan carrier must ensure that the portal:
2 (1) is compliant with the federal Health Insurance
3 Portability and Accountability Act of 1996 and the
4 regulations promulgated thereunder and allows dental care
5 providers to submit claims electronically and directly to
6 the dental plan carrier. The portal shall be provided free
7 of charge to the dental care provider;
8 (2) accepts attachments, including, but not limited
9 to, x-rays and other supporting information for claims, in
10 an electronic format with the initial electronic claim's
11 submission and any further submissions thereafter; and
12 (3) offers remittance advice with the corresponding
13 payment that outlines individually per claim: the name of
14 the patient; the date of service; the service code or, if
15 no service code is available, a service description; the
16 amount being paid; the claim number; and other identifying
17 claim information found on an explanation of benefits
18 form.
19 (215 ILCS 111/40 new)
20 Sec. 40. Payment. Nothing in this Act requires a dental
21 care provider to only accept electronic payment from a dental
22 plan carrier.
23 Section 99. Effective date. This Act takes effect upon
24 becoming law, except that Sections 30, 35, and 40 of the
25 Uniform Electronic Transactions in Dental Care Billing Act
HB1864 Engrossed - 7 - LRB104 06097 BAB 16130 b
HB1864 Engrossed- 8 -LRB104 06097 BAB 16130 b HB1864 Engrossed - 8 - LRB104 06097 BAB 16130 b
HB1864 Engrossed - 8 - LRB104 06097 BAB 16130 b
1 take effect January 1, 2027.
HB1864 Engrossed - 8 - LRB104 06097 BAB 16130 b