Bill Text: IL HB4789 | 2023-2024 | 103rd General Assembly | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
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
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
| ||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
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 | adding Section 355d as follows:
| |||||||||||||||||||
6 | (215 ILCS 5/355d new) | |||||||||||||||||||
7 | Sec. 355d. Denials of claims submitted after prior | |||||||||||||||||||
8 | authorization. | |||||||||||||||||||
9 | (a) As used in this Section, "prior authorization" means | |||||||||||||||||||
10 | any predetermination, prior authorization, or similar | |||||||||||||||||||
11 | authorization that is verifiable, whether through issuance or | |||||||||||||||||||
12 | letter, facsimile, email, or similar means, indicating that a | |||||||||||||||||||
13 | specific procedure is, or multiple procedures are, covered | |||||||||||||||||||
14 | under the patient's dental plan and reimbursable at a specific | |||||||||||||||||||
15 | amount, subject to applicable coinsurance and deductibles, and | |||||||||||||||||||
16 | issued in response to a request submitted by a dentist using a | |||||||||||||||||||
17 | format prescribed by the insurer. | |||||||||||||||||||
18 | (b) No insurer, dental service plan corporation, insurance | |||||||||||||||||||
19 | network leasing company, or any company that amends, delivers, | |||||||||||||||||||
20 | issues, or renews an individual or group policy of accident | |||||||||||||||||||
21 | and health insurance on or after the effective date of this | |||||||||||||||||||
22 | amendatory Act of the 103rd General Assembly that provides | |||||||||||||||||||
23 | dental insurance shall deny any claim subsequently submitted |
| |||||||
| |||||||
1 | for procedures specifically included in a prior authorization | ||||||
2 | unless at least one of the following circumstances applies for | ||||||
3 | each procedure denied: | ||||||
4 | (1) benefit limitations, such as annual maximums and | ||||||
5 | frequency limitations, that were not applicable at the | ||||||
6 | time of the prior authorization are reached due to | ||||||
7 | utilization after issuance of the prior authorization; | ||||||
8 | (2) the documentation for the claim provided by the | ||||||
9 | person submitting the claim clearly fails to support the | ||||||
10 | claim as originally authorized; | ||||||
11 | (3) if, after the issuance of the prior authorization, | ||||||
12 | new procedures are provided to the patient or a change in | ||||||
13 | the condition of the patient occurs such that the prior | ||||||
14 | authorized procedure would no longer be considered | ||||||
15 | medically necessary based on the prevailing standard of | ||||||
16 | care; | ||||||
17 | (4) if, after the issuance of the prior authorization, | ||||||
18 | new procedures are provided to the patient or a change in | ||||||
19 | the condition of the patient occurs such that the prior | ||||||
20 | authorized procedure would, at that time, require | ||||||
21 | disapproval pursuant to the terms and conditions for | ||||||
22 | coverage under the plan for the patient in effect at the | ||||||
23 | time the prior authorization was used; or | ||||||
24 | (5) the claim was denied by a dental service | ||||||
25 | contractor due to one of the following reasons: | ||||||
26 | (A) another payor is responsible for the payment; |
| |||||||
| |||||||