Bill Text: IL HB4789 | 2023-2024 | 103rd General Assembly | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Reinserts the provisions of the introduced bill with the following changes. Makes a change in the definition of "prior authorization". Defines "dental carrier" as 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. Changes references from "dental service contractor" and "insurer" to "dental carrier". Provides that beginning on the effective date of the amendatory Act, a dental carrier shall not deny any claim subsequently submitted for procedures specifically included in a prior authorization unless certain circumstances apply. Removes language providing that no insurer, dental service plan corporation, insurance network leasing company, or any company that amends, delivers, issues, or renews an individual or group policy of accident and health insurance that provides dental insurance on or after the effective date of the amendatory Act shall deny any claim subsequently submitted for procedures specifically included in a prior authorization unless certain circumstances apply. Further amends the Illinois Insurance Code. In a provision requiring contracting entities to provide notification before any scheduled assignment or lease of the network to which the provider is a contracted provider, requires the notification to provide the specific URL address where the following are located: 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 (instead of the notification including 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). Requires the notification to provide instructions for how the provider may obtain a copy of those materials. Amends the Limited Health Service Organization Act and Voluntary Health Services Plans Act to make conforming changes.

Spectrum: Slight Partisan Bill (Republican 5-3)

Status: (Passed) 2024-08-09 - Public Act . . . . . . . . . 103-0832 [HB4789 Detail]

Download: Illinois-2023-HB4789-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4789 Introduced , by Rep. Bob Morgan SYNOPSIS AS INTRODUCED:
215 ILCS 5/355d new
Amends the Illinois Insurance Code. Provides that no insurer, dental service plan corporation, insurance network leasing company, or any company that amends, delivers, issues, or renews an individual or group policy of accident and health insurance that provides dental insurance on or after the effective date of the amendatory Act shall deny any claim subsequently submitted for procedures specifically included in a prior authorization unless certain circumstances apply. Provides that a dental service contractor shall not recoup a claim solely due to a loss of coverage for a patient or ineligibility if, at the time of treatment, the dental service contractor erroneously confirmed coverage and eligibility, but had sufficient information available to the dental service contractor indicating that the patient was no longer covered or was ineligible for coverage. Prohibits waiver of the provisions by contract.
LRB103 36280 RPS 66377 b
A BILL FOR
HB4789 LRB103 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
adding Section 355d as follows:
(215 ILCS 5/355d new)
Sec. 355d. Denials of claims submitted after prior
authorization.
(a) As used in this Section, "prior authorization" means
any predetermination, prior authorization, or similar
authorization 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 insurer.
(b) No insurer, dental service plan corporation, insurance
network leasing company, or any company that amends, delivers,
issues, or renews an individual or group policy of accident
and health insurance on or after the effective date of this
amendatory Act of the 103rd General Assembly that provides
dental insurance shall deny any claim subsequently submitted

HB4789 - 2 - LRB103 36280 RPS 66377 b
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 service
contractor due to one of the following reasons:
(A) another payor is responsible for the payment;

HB4789 - 3 - LRB103 36280 RPS 66377 b