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HB1864 Enrolled LRB104 06097 BAB 16130 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Uniform Electronic Transactions in Dental
5 Care Billing Act is amended by changing Sections 5, 15, 20, and
6 25 and by adding Sections 30, 35, and 40 as follows:
7 (215 ILCS 111/5)
8 Sec. 5. Purpose. The purpose of this Act is to standardize
9 the forms used in the billing and reimbursement of dental
10 care, reduce the number of forms used, increase efficiency in
11 the reimbursement of dental care through standardization, and
12 encourage the use of and prescribe a timetable for
13 implementation of a secure electronic data interchange of
14 dental care expenses and reimbursement.
15 (Source: P.A. 102-146, eff. 7-23-21.)
16 (215 ILCS 111/15)
17 Sec. 15. Definitions. As used in this Act:
18 "Department" means the Department of Insurance.
19 "Director" means the Director of Insurance.
20 "Dental care provider" means a dentist who bills for
21 services in Illinois.
22 "Dental plan carrier" means an entity subject to the
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1 insurance laws and regulations of this State or subject to the
2 jurisdiction of the Director that contracts or offers to
3 contract to provide, deliver, arrange for, pay for, or
4 reimburse any of the costs of dental care services, including
5 an accident and health insurance company, a health maintenance
6 organization, a limited health service organization, a dental
7 service plan corporation, a health services plan corporation,
8 a voluntary health services plan, or any other entity
9 providing a plan of dental insurance, dental benefits, or
10 dental health care services.
11 "Portal" means a website or reasonably similar method of
12 sharing information that: (i) is compliant with the federal
13 Health Insurance Portability and Accountability Act of 1996
14 and the regulations promulgated thereunder, and (ii) provides
15 resources and information to dental care providers and
16 subscribers.
17 (Source: P.A. 102-146, eff. 7-23-21.)
18 (215 ILCS 111/20)
19 Sec. 20. Uniform electronic claims and eligibility
20 transactions required.
21 (a) Beginning January 1, 2027 2026, no dental plan carrier
22 is required to accept from a dental care provider eligibility
23 for a dental plan transaction or dental care claims or
24 equivalent encounter information transaction except as
25 provided in this Act.
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1 (b) All dental plan carriers and dental care providers
2 must exchange claims and eligibility information
3 electronically using the standard electronic data interchange
4 transactions for claims submissions, payments, and
5 verification of benefits required under the Health Insurance
6 Portability and Accountability Act in order to be compensable
7 by the dental plan carrier.
8 (c) All dental plan carriers and dental care providers
9 must comply with applicable State and federal privacy and
10 security laws, and regulations when conducting the exchange of
11 information under this Act.
12 (Source: P.A. 102-146, eff. 7-23-21; 103-705, eff. 7-19-24.)
13 (215 ILCS 111/25)
14 Sec. 25. Rules; modification of rules.
15 (a) The Department may shall adopt rules as necessary to
16 implement this Act and may establish further exemptions to
17 this Act by rule.
18 (b) A dental plan carrier or dental care provider may not
19 add to or modify the uniform electronic claims and eligibility
20 requirements adopted by the Department.
21 (Source: P.A. 102-146, eff. 7-23-21.)
22 (215 ILCS 111/30 new)
23 Sec. 30. Exemptions.
24 (a) Notwithstanding any other provision of this Act, a
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1 dental care provider shall not be required to submit claims
2 electronically under any of the following circumstances:
3 (1) There is a temporary technological event, due to
4 unforeseen practice disruptions, including, but not
5 limited to, natural disasters, physical damage to the
6 practice, or damage to the data system that prevents a
7 claim from being submitted electronically for more than 14
8 days.
9 (2) a dental care provider works less than 16 hours
10 per week and is a solo practitioner.
11 (3) The dental care provider is a dental care provider
12 who is temporarily operating a practice for another dental
13 care provider who is unable to practice.
14 (b) A dental care provider who is exempted from filing
15 claims electronically under this Section shall file a form
16 with the Department indicating the applicable exemption. The
17 Department shall provide the form no later than January 1,
18 2027.
19 (c) Any dental care provider that starts a dental care
20 practice or purchases a practice and who was previously
21 exempted from the requirements of this Act shall have 2 years
22 from the date the practice is started or purchased to comply
23 with this Act.
24 (215 ILCS 111/35 new)
25 Sec. 35. Eligibility and benefit verification portal.
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1 (a) Each dental plan carrier shall establish a portal as
2 described in this Section and shall include information about
3 each type of subscription contract that is sufficient to allow
4 subscribers and dental care providers to determine the covered
5 services under each subscription contract and the payment or
6 reimbursement amounts for those covered services at the
7 procedure level. The information in the portal shall include
8 the following, as appropriate:
9 (1) Effective date of plan.
10 (2) Termination date of plan.
11 (3) Coordination of benefits; standard or
12 non-duplicating.
13 (4) Claim address.
14 (5) Payer identification.
15 (6) Covered services.
16 (7) Whether a deductible applies and to which
17 services.
18 (8) Remaining deductible: family.
19 (9) Remaining deductible: individual.
20 (10) In-network coinsurance percentage.
21 (11) Out-of-network coinsurance percentage.
22 (12) Remaining plan maximum.
23 (13) Remaining lifetime maximum, if applicable.
24 (14) Previous 12 months of claim payments applied to
25 the member's annual maximum or deductible to help
26 determine if a benefit has been used outside of the
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1 primary office.
2 (15) Age limitation.
3 (16) Frequency limit by time period.
4 (17) Frequency limit by tooth number.
5 (18) Next available service date or previous service
6 dates based on any frequency limit due to prior treatment
7 history or added custom benefits, such as medical
8 conditions and roll-over.
9 (19) Number of quads benefited per visit if a specific
10 benefit limitation exists that may limit the number of
11 quads treated and services rendered per visit.
12 (20) Waiting period due to preexisting condition or
13 missing tooth limitation.
14 (21) Prior authorization requirements.
15 (22) A comprehensive list (or procedure code level
16 lookup tool) of all current American Dental Association
17 CDT Codes stating if they are covered, the percentage of
18 coverage, and if there are any conditions that preclude
19 coverage.
20 (b) At minimum, the portal shall provide current and
21 accurate real-time benefit eligibility and benefits
22 information. It is the responsibility of the dental plan
23 carrier to ensure patient eligibility and benefits reporting
24 is timely and accurate.
25 (c) A dental plan carrier must ensure that the portal:
26 (1) is compliant with the federal Health Insurance
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1 Portability and Accountability Act of 1996 and the
2 regulations promulgated thereunder and allows dental care
3 providers to submit claims electronically and directly to
4 the dental plan carrier. The portal shall be provided free
5 of charge to the dental care provider;
6 (2) accepts attachments, including, but not limited
7 to, x-rays and other supporting information for claims, in
8 an electronic format with the initial electronic claim's
9 submission and any further submissions thereafter; and
10 (3) offers remittance advice with the corresponding
11 payment that outlines individually per claim: the name of
12 the patient; the date of service; the service code or, if
13 no service code is available, a service description; the
14 amount being paid; the claim number; and other identifying
15 claim information found on an explanation of benefits
16 form.
17 (215 ILCS 111/40 new)
18 Sec. 40. Payment. Nothing in this Act requires a dental
19 care provider to only accept electronic payment from a dental
20 plan carrier.
21 Section 99. Effective date. This Act takes effect upon
22 becoming law, except that Sections 30, 35, and 40 of the
23 Uniform Electronic Transactions in Dental Care Billing Act
24 take effect January 1, 2027.Every fact on this page links to its source, starting with the official bill record.