103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB4789

 

Introduced 2/6/2024, 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

 

HB4789LRB103 36280 RPS 66377 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5adding Section 355d as follows:
 
6    (215 ILCS 5/355d new)
7    Sec. 355d. Denials of claims submitted after prior
8authorization.
9    (a) As used in this Section, "prior authorization" means
10any predetermination, prior authorization, or similar
11authorization that is verifiable, whether through issuance or
12letter, facsimile, email, or similar means, indicating that a
13specific procedure is, or multiple procedures are, covered
14under the patient's dental plan and reimbursable at a specific
15amount, subject to applicable coinsurance and deductibles, and
16issued in response to a request submitted by a dentist using a
17format prescribed by the insurer.
18    (b) No insurer, dental service plan corporation, insurance
19network leasing company, or any company that amends, delivers,
20issues, or renews an individual or group policy of accident
21and health insurance on or after the effective date of this
22amendatory Act of the 103rd General Assembly that provides
23dental insurance shall deny any claim subsequently submitted

 

 

HB4789- 2 -LRB103 36280 RPS 66377 b

1for procedures specifically included in a prior authorization
2unless at least one of the following circumstances applies for
3each 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;

 

 

HB4789- 3 -LRB103 36280 RPS 66377 b

1            (B) the dentist has already been paid for the
2        procedures identified on the claim;
3            (C) the claim was submitted fraudulently or the
4        prior authorization was based in whole or material
5        part on erroneous information provided to the insurer,
6        dental service plan corporation, insurance network
7        leasing company, or company that amends, delivers,
8        issues, or renews an individual or group policy of
9        accident and health insurance that provides dental
10        insurance; or
11            (D) the person receiving the procedure was not
12        eligible for the procedure on the date of service and
13        the dental service contractor did not know, and with
14        the exercise of reasonable care could not have known,
15        that person's eligibility status.
16    A dental service contractor shall not recoup a claim
17solely due to a loss of coverage of a patient or ineligibility
18if, at the time of treatment, the dental service contractor
19erroneously confirmed coverage and eligibility, but had
20sufficient information available to the dental service
21contractor indicating that the patient was no longer covered
22or was ineligible for coverage.
23    (c) The provisions of this Section may not be waived by
24contract. Any contractual arrangement in conflict with the
25provisions of this Section or that purports to waive any
26requirement of this Section is null and void.