103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5317

 

Introduced 2/9/2024, by Rep. Robert "Bob" Rita

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 111/15
215 ILCS 111/20
215 ILCS 111/25
215 ILCS 111/30 new
215 ILCS 111/35 new
215 ILCS 111/40 new
215 ILCS 111/45 new

    Amends the Uniform Electronic Transactions in Dental Care Billing Act. Provides that beginning January 1, 2027 (instead of 2025), no dental plan carrier is required to accept from a dental care provider eligibility for a dental plan transaction or dental care claims or equivalent encounter information transaction. Sets forth exemptions from the requirements of the Act, and requires a dental care provider who is exempt from the requirements of the Act to file a form with the Department of Insurance indicating the applicable exemption. Requires each dental plan carrier to establish a portal that provides certain benefit and billing information. Requires a dental plan carrier to establish an electronic portal that allows dental care providers to submit claims electronically and directly to the dental care provider; accept attachments in an electronic format with the initial electronic claim's submission; and provide remittance advice with the corresponding payment. Provides that nothing in the Act requires a dental care provider to only accept electronic payment from a dental plan carrier. Provides that dental plan carriers shall allow alternative forms of payment, without additional fees or charges, to a dental care provider, if requested. Effective immediately.


LRB103 38524 RPS 68660 b

 

 

A BILL FOR

 

HB5317LRB103 38524 RPS 68660 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 Uniform Electronic Transactions in Dental
5Care Billing Act is amended by changing Sections 15, 20, and 25
6and by adding Sections 30, 35, 40, and 45 as follows:
 
7    (215 ILCS 111/15)
8    Sec. 15. Definitions. As used in this Act:
9    "Department" means the Department of Insurance.
10    "Director" means the Director of Insurance.
11    "Dental care provider" means a dentist who bills for
12services in Illinois.
13    "Dental plan carrier" means an entity subject to the
14insurance laws and regulations of this State or subject to the
15jurisdiction of the Director that contracts or offers to
16contract to provide, deliver, arrange for, pay for, or
17reimburse any of the costs of dental care services, including
18an accident and health insurance company, a health maintenance
19organization, a limited health service organization, a dental
20service plan corporation, a health services plan corporation,
21a voluntary health services plan, or any other entity
22providing a plan of dental insurance, dental benefits, or
23dental health care services.

 

 

HB5317- 2 -LRB103 38524 RPS 68660 b

1    "Portal" means a website or reasonably similar method of
2sharing information that (i) is compliant with the federal
3Health Insurance Portability and Accountability Act of 1996
4and the regulations promulgated thereunder, (ii) provides
5resources and information to dentists and subscribers, and
6(iii) is compatible with dental software so universal
7accessibility may be achieved.
8(Source: P.A. 102-146, eff. 7-23-21.)
 
9    (215 ILCS 111/20)
10    Sec. 20. Uniform electronic claims and eligibility
11transactions required.
12    (a) Beginning January 1, 2027 2025, no dental plan carrier
13is required to accept from a dental care provider eligibility
14for a dental plan transaction or dental care claims or
15equivalent encounter information transaction except as
16provided in this Act.
17    (b) All dental plan carriers and dental care providers
18must exchange claims and eligibility information
19electronically using the standard electronic data interchange
20transactions for claims submissions, payments, and
21verification of benefits required under the Health Insurance
22Portability and Accountability Act in order to be compensable
23by the dental plan carrier.
24(Source: P.A. 102-146, eff. 7-23-21.)
 

 

 

HB5317- 3 -LRB103 38524 RPS 68660 b

1    (215 ILCS 111/25)
2    Sec. 25. Rules; modification of rules.
3    (a) The Department may shall adopt rules as necessary to
4implement this Act and may establish further exemptions to
5this Act by rule.
6    (b) A dental plan carrier or dental care provider may not
7add to or modify the uniform electronic claims and eligibility
8requirements adopted by the Department.
9(Source: P.A. 102-146, eff. 7-23-21.)
 
10    (215 ILCS 111/30 new)
11    Sec. 30. Exemptions. Notwithstanding any other provision
12of this Act, a dental care provider shall not be required to
13submit claims electronically under any of the following
14circumstances:
15        (1) The dental care provider is with a dental practice
16    that, including the dental care provider, employs 4 or
17    fewer full-time or full-time equivalent employees.
18        (2) There is a temporary technological or electrical
19    failure that prevents a claim from being submitted
20    electronically.
21        (3) The dental care provider graduated from a dental
22    school in 1985 or before.
23        (4) The dental care provider graduated from a dental
24    school within 10 years before the effective date of this
25    amendatory Act of the 103rd General Assembly and meets one

 

 

HB5317- 4 -LRB103 38524 RPS 68660 b

1    of the following criteria:
2            (A) The dental care provider started his or her
3        own practice.
4            (B) The dental care provider has purchased a
5        practice that has been previously exempted from the
6        requirements of this Act.
7        (5) The dental care provider demonstrates financial
8    difficulties in buying or managing an electronic claims
9    submission software system.
10        (6) The dental care provider has a disability or
11    medical reason that prohibits the dental care provider
12    from submitting claims electronically.
13        (7) The dental care provider is a temporary dentist
14    operating a practice for another dentist who is
15    temporarily unable to practice.
16        (8) There are other unforeseen practice disruptions,
17    including, but not limited to, natural disasters, physical
18    damage to the practice, or damage to the data system.
19    A dental care provider who is exempted from filing claims
20electronically under this Section shall file a form with the
21Department indicating the applicable exemption. The Department
22shall provide the form no later than January 1, 2027.
 
23    (215 ILCS 111/35 new)
24    Sec. 35. Eligibility and benefit verification portal.
25    (a) Each dental plan carrier shall establish a portal as

 

 

HB5317- 5 -LRB103 38524 RPS 68660 b

1described in this Section and shall include information about
2each type of subscription contract that is sufficient to allow
3subscribers and dentists to determine the covered services
4under each subscription contract and the payment or
5reimbursement amounts for those covered services at the
6procedure level. The information in the portal shall include
7the following, as appropriate:
8        (1) Effective date of plan.
9        (2) Status of plan.
10        (3) Termination date of plan.
11        (4) Coordination of benefits; standard or
12    non-duplicating.
13        (5) Claim address.
14        (6) Payer identification.
15        (7) Covered services.
16        (8) Whether a deductible applies and to which
17    services.
18        (9) Remaining deductible: family.
19        (10) Remaining deductible: individual.
20        (11) Preferred in-network co-insurance amount.
21        (12) In-network co-insurance amount.
22        (13) Out-of-network co-insurance amount.
23        (14) Preferred in-network co-payment amount.
24        (15) In-network co-payment amount.
25        (16) Out-of-network co-payment amount.
26        (17) Remaining plan maximum.

 

 

HB5317- 6 -LRB103 38524 RPS 68660 b

1        (18) Remaining lifetime maximum.
2        (19) Last treatment plan payment date applied to the
3    annual maximum or deductible to help determine if a
4    benefit has been used outside of the primary office.
5        (20) Age limitation.
6        (21) Frequency limit by time period.
7        (22) Frequency limit by tooth number.
8        (23) Next available service date based on any
9    frequency limit due to prior treatment history or added
10    custom benefits, such as medical conditions and roll-over.
11        (24) Whether there is a missing tooth clause.
12        (25) Number of quads benefited per visit.
13        (26) Waiting period due to preexisting condition or
14    missing tooth limitation.
15        (27) Prior authorization requirements.
16        (28) Processing policies, such as bundling,
17    downcoding, least expensive alternative treatment
18    requirements, fees disallowed in conjunction with other
19    treatments, and limitations by location.
20        (29) A comprehensive list of all current American
21    Dental Association Codes stating if they are covered, the
22    percentage of coverage, and if there are any conditions
23    that preclude coverage.
24    (b) At minimum, the portal shall provide current and
25accurate real-time benefit eligibility and benefits
26information. It is the responsibility of the dental plan

 

 

HB5317- 7 -LRB103 38524 RPS 68660 b

1carrier to ensure patient eligibility and benefits reporting
2is timely and accurate.
 
3    (215 ILCS 111/40 new)
4    Sec. 40. Dental plan carrier requirements. A dental plan
5carrier must:
6        (1) Provide an electronic portal that is compliant
7    with the federal Health Insurance Portability and
8    Accountability Act of 1996 and the regulations promulgated
9    thereunder and that allows dental care providers to submit
10    claims electronically and directly to dental plan carrier.
11    The portal shall be provided free of charge to the dental
12    care provider.
13        (2) Accept attachments, including, but not limited to,
14    x-rays and other supporting information for claims, in an
15    electronic format with the initial electronic claim's
16    submission and any further submissions thereafter.
17        (3) Provide remittance advice with the corresponding
18    payment that outlines individually per claim: the name of
19    the patient; the date of service; the service code or, if
20    no service code is available, a service description; the
21    amount being paid; the claim number; and other identifying
22    claim information found on an explanation of benefits
23    form.
 
24    (215 ILCS 111/45 new)

 

 

HB5317- 8 -LRB103 38524 RPS 68660 b

1    Sec. 45. Payment. Nothing in this Act requires a dental
2care provider to only accept electronic payment from a dental
3plan carrier. Dental plan carriers shall allow alternative
4forms of payment, without additional fees or charges, to a
5dental care provider, if requested.
 
6    Section 99. Effective date. This Act takes effect upon
7becoming law.