Illinois General Assembly - Full Text of SB3305
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Full Text of SB3305  103rd General Assembly


Sen. Laura Fine

Filed: 4/10/2024





10300SB3305sam001LRB103 37060 RPS 72164 a


2    AMENDMENT NO. ______. Amend Senate Bill 3305 by replacing
3everything after the enacting clause with the following:
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



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1reimburse any of the costs of dental care services, including
2an accident and health insurance company, a health maintenance
3organization, a limited health service organization, a dental
4service plan corporation, a health services plan corporation,
5a voluntary health services plan, or any other entity
6providing a plan of dental insurance, dental benefits, or
7dental health care services.
8    "Portal" means a website or reasonably similar method of
9sharing information that (i) is compliant with the federal
10Health Insurance Portability and Accountability Act of 1996
11and the regulations promulgated thereunder, (ii) provides
12resources and information to dentists and subscribers, and
13(iii) is compatible with dental software so universal
14accessibility may be achieved.
15(Source: P.A. 102-146, eff. 7-23-21.)
16    (215 ILCS 111/20)
17    Sec. 20. Uniform electronic claims and eligibility
18transactions required.
19    (a) Beginning January 1, 2027 2025, no dental plan carrier
20is required to accept from a dental care provider eligibility
21for a dental plan transaction or dental care claims or
22equivalent encounter information transaction except as
23provided in this Act.
24    (b) All dental plan carriers and dental care providers
25must exchange claims and eligibility information



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1electronically using the standard electronic data interchange
2transactions for claims submissions, payments, and
3verification of benefits required under the Health Insurance
4Portability and Accountability Act in order to be compensable
5by the dental plan carrier.
6(Source: P.A. 102-146, eff. 7-23-21.)
7    (215 ILCS 111/25)
8    Sec. 25. Rules; modification of rules.
9    (a) The Department may shall adopt rules as necessary to
10implement this Act and may establish further exemptions to
11this Act by rule.
12    (b) A dental plan carrier or dental care provider may not
13add to or modify the uniform electronic claims and eligibility
14requirements adopted by the Department.
15(Source: P.A. 102-146, eff. 7-23-21.)
16    (215 ILCS 111/30 new)
17    Sec. 30. Exemptions. Notwithstanding any other provision
18of this Act, a dental care provider shall not be required to
19submit claims electronically under any of the following
21        (1) The dental care provider is with a dental practice
22    that, including the dental care provider, employs 4 or
23    fewer full-time or full-time equivalent employees.
24        (2) There is a temporary technological or electrical



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1    failure that prevents a claim from being submitted
2    electronically.
3        (3) The dental care provider graduated from a dental
4    school in 1985 or before.
5        (4) The dental care provider graduated from a dental
6    school within 10 years before the effective date of this
7    amendatory Act of the 103rd General Assembly and meets one
8    of the following criteria:
9            (A) The dental care provider started his or her
10        own practice.
11            (B) The dental care provider has purchased a
12        practice that has been previously exempted from the
13        requirements of this Act.
14        (5) The dental care provider demonstrates financial
15    difficulties in buying or managing an electronic claims
16    submission software system.
17        (6) The dental care provider has a disability or
18    medical reason that prohibits the dental care provider
19    from submitting claims electronically.
20        (7) The dental care provider is a temporary dentist
21    operating a practice for another dentist who is
22    temporarily unable to practice.
23        (8) There are other unforeseen practice disruptions,
24    including, but not limited to, natural disasters, physical
25    damage to the practice, or damage to the data system.
26    A dental care provider who is exempted from filing claims



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1electronically under this Section shall file a form with the
2Department indicating the applicable exemption. The Department
3shall provide the form no later than January 1, 2027.
4    (215 ILCS 111/35 new)
5    Sec. 35. Eligibility and benefit verification portal.
6    (a) Each dental plan carrier shall establish a portal as
7described in this Section and shall include information about
8each type of subscription contract that is sufficient to allow
9subscribers and dentists to determine the covered services
10under each subscription contract and the payment or
11reimbursement amounts for those covered services at the
12procedure level. The information in the portal shall include
13the following, as appropriate:
14        (1) Effective date of plan.
15        (2) Status of plan.
16        (3) Termination date of plan.
17        (4) Coordination of benefits; standard or
18    non-duplicating.
19        (5) Claim address.
20        (6) Payer identification.
21        (7) Covered services.
22        (8) Whether a deductible applies and to which
23    services.
24        (9) Remaining deductible: family.
25        (10) Remaining deductible: individual.



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1        (11) Preferred in-network co-insurance amount.
2        (12) In-network co-insurance amount.
3        (13) Out-of-network co-insurance amount.
4        (14) Preferred in-network co-payment amount.
5        (15) In-network co-payment amount.
6        (16) Out-of-network co-payment amount.
7        (17) Remaining plan maximum.
8        (18) Remaining lifetime maximum.
9        (19) Last treatment plan payment date applied to the
10    annual maximum or deductible to help determine if a
11    benefit has been used outside of the primary office.
12        (20) Age limitation.
13        (21) Frequency limit by time period.
14        (22) Frequency limit by tooth number.
15        (23) Next available service date based on any
16    frequency limit due to prior treatment history or added
17    custom benefits, such as medical conditions and roll-over.
18        (24) Whether there is a missing tooth clause.
19        (25) Number of quads benefited per visit.
20        (26) Waiting period due to preexisting condition or
21    missing tooth limitation.
22        (27) Prior authorization requirements.
23        (28) Processing policies, such as bundling,
24    downcoding, least expensive alternative treatment
25    requirements, fees disallowed in conjunction with other
26    treatments, and limitations by location.



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1        (29) A comprehensive list of all current American
2    Dental Association Codes stating if they are covered, the
3    percentage of coverage, and if there are any conditions
4    that preclude coverage.
5    (b) At minimum, the portal shall provide current and
6accurate real-time benefit eligibility and benefits
7information. It is the responsibility of the dental plan
8carrier to ensure patient eligibility and benefits reporting
9is timely and accurate.
10    (215 ILCS 111/40 new)
11    Sec. 40. Dental plan carrier requirements. A dental plan
12carrier must:
13        (1) Provide an electronic portal that is compliant
14    with the federal Health Insurance Portability and
15    Accountability Act of 1996 and the regulations promulgated
16    thereunder and that allows dental care providers to submit
17    claims electronically and directly to dental plan carrier.
18    The portal shall be provided free of charge to the dental
19    care provider.
20        (2) Accept attachments, including, but not limited to,
21    x-rays and other supporting information for claims, in an
22    electronic format with the initial electronic claim's
23    submission and any further submissions thereafter.
24        (3) Provide remittance advice with the corresponding
25    payment that outlines individually per claim: the name of



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1    the patient; the date of service; the service code or, if
2    no service code is available, a service description; the
3    amount being paid; the claim number; and other identifying
4    claim information found on an explanation of benefits
5    form.
6    (215 ILCS 111/45 new)
7    Sec. 45. Payment. Nothing in this Act requires a dental
8care provider to only accept electronic payment from a dental
9plan carrier. Dental plan carriers shall allow alternative
10forms of payment, without additional fees or charges, to a
11dental care provider, if requested.
12    Section 99. Effective date. This Act takes effect upon
13becoming law.".