215 ILCS 5/355d

(215 ILCS 5/355d)

(This Section may contain text from a Public Act with a delayed effective date)

Sec. 355d. Denials of claims submitted after prior authorization.

(a) In this Section:

"Dental carrier" means 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.

"Prior authorization" means any written communication that is verifiable, whether through issuance or letter, facsimile, email, or similar means, indicating that a specific procedure is, or multiple procedures are, covered under the patient's dental plan and reimbursable at a specific amount, subject to applicable coinsurance and deductibles, and issued in response to a request submitted by a dentist using a format prescribed by the dental carrier.

(b) Beginning on the effective date of this amendatory Act of the 103rd General Assembly, a dental carrier shall not deny any claim subsequently submitted for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:

(1) benefit limitations, such as annual maximums and frequency limitations, that were not applicable at the time of the prior authorization are reached due to utilization after issuance of the prior authorization;

(2) the documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized;

(3) if, after the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary based on the prevailing standard of care;

(4) if, after the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would, at that time, require disapproval pursuant to the terms and conditions for coverage under the plan for the patient in effect at the time the prior authorization was used; or

(5) the claim was denied by a dental carrier due to one of the following reasons:

(A) another payor is responsible for the payment;

(B) the dentist has already been paid for the procedures identified on the claim;

(C) the claim was submitted fraudulently or the prior authorization was based in whole or material part on erroneous information provided to the dental carrier; or

(D) the person receiving the procedure was not eligible for the procedure on the date of service and the dental carrier did not know, and with the exercise of reasonable care could not have known, that person's eligibility status.

A dental carrier shall not recoup a claim solely due to a loss of coverage of a patient or ineligibility if, at the time of treatment, the dental carrier erroneously confirmed coverage and eligibility, but had sufficient information available to the dental carrier indicating that the patient was no longer covered or was ineligible for coverage.

(c) The provisions of this Section may not be waived by contract. Any contractual agreement entered into or amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly that is in conflict with this Section or that purports to waive any requirement of this Section is null and void.

(Source: P.A. 103-832, eff. 1-1-25.)