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| | HB4789 Engrossed | - 2 - | LRB103 36280 RPS 66377 b |
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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 |
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| | HB4789 Engrossed | - 3 - | LRB103 36280 RPS 66377 b |
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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 .)
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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 |
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| | HB4789 Engrossed | - 4 - | LRB103 36280 RPS 66377 b |
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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; |
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| | HB4789 Engrossed | - 5 - | LRB103 36280 RPS 66377 b |
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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 arrangement in conflict with the |
18 | | provisions of this Section or that purports to waive any |
19 | | requirement of this Section is null and void.
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20 | | Section 10. The Limited Health Service Organization Act is |
21 | | amended by changing Section 4003 as follows:
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22 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) |
23 | | Sec. 4003. Illinois Insurance Code provisions. Limited |
24 | | health service organizations shall be subject to the |
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| | HB4789 Engrossed | - 6 - | LRB103 36280 RPS 66377 b |
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1 | | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, |
2 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, |
3 | | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2, |
4 | | 355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10, |
5 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, |
6 | | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, |
7 | | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, |
8 | | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, |
9 | | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, |
10 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. |
11 | | Nothing in this Section shall require a limited health care |
12 | | plan to cover any service that is not a limited health service. |
13 | | For purposes of the Illinois Insurance Code, except for |
14 | | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited |
15 | | health service organizations in the following categories are |
16 | | deemed to be domestic companies: |
17 | | (1) a corporation under the laws of this State; or |
18 | | (2) a corporation organized under the laws of another |
19 | | state, 30% or more of the enrollees of which are residents |
20 | | of this State, except a corporation subject to |
21 | | substantially the same requirements in its state of |
22 | | organization as is a domestic company under Article VIII |
23 | | 1/2 of the Illinois Insurance Code. |
24 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; |
25 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. |
26 | | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, |
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| | HB4789 Engrossed | - 7 - | LRB103 36280 RPS 66377 b |
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1 | | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; |
2 | | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. |
3 | | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
4 | | eff. 1-1-24; revised 8-29-23.)
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5 | | Section 15. The Voluntary Health Services Plans Act is |
6 | | amended by changing Section 10 as follows:
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7 | | (215 ILCS 165/10) (from Ch. 32, par. 604) |
8 | | Sec. 10. Application of Insurance Code provisions. Health |
9 | | services plan corporations and all persons interested therein |
10 | | or dealing therewith shall be subject to the provisions of |
11 | | Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, |
12 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, |
13 | | 355d, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, |
14 | | 356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, |
15 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, |
16 | | 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, |
17 | | 356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, |
18 | | 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, |
19 | | 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, |
20 | | 356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401, |
21 | | 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) |
22 | | and (15) of Section 367 of the Illinois Insurance Code. |
23 | | Rulemaking authority to implement Public Act 95-1045, if |
24 | | any, is conditioned on the rules being adopted in accordance |