Bill Amendment: IL HB1864 | 2025-2026 | 104th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: DENTAL CARE-ELECTRONIC BILLING

Status: 2025-08-15 - Public Act . . . . . . . . . 104-0203 [HB1864 Detail]

Download: Illinois-2025-HB1864-House_Amendment_001.html

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Rep. Robert "Bob" Rita

Filed: 4/2/2025

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AMENDMENT TO HOUSE BILL 1864
AMENDMENT NO. ______. Amend House Bill 1864 by replacing
everything after the enacting clause with the following:
"Section 5. The Uniform Electronic Transactions in Dental
Care Billing Act is amended by changing Sections 5, 15, 20, and
25 and by adding Sections 30, 35, and 40 as follows:
(215 ILCS 111/5)
Sec. 5. Purpose. The purpose of this Act is to standardize
the forms used in the billing and reimbursement of dental
care, reduce the number of forms used, increase efficiency in
the reimbursement of dental care through standardization, and
encourage the use of and prescribe a timetable for
implementation of a secure electronic data interchange of
dental care expenses and reimbursement.
(Source: P.A. 102-146, eff. 7-23-21.)

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(215 ILCS 111/15)
Sec. 15. Definitions. As used in this Act:
"Department" means the Department of Insurance.
"Director" means the Director of Insurance.
"Dental care provider" means a dentist who bills for
services in Illinois.
"Dental plan carrier" means an entity subject to the
insurance laws and regulations of this State or subject to the
jurisdiction of the Director that contracts or offers to
contract to provide, deliver, arrange for, pay for, or
reimburse any of the costs of dental care services, including
an accident and health insurance company, a health maintenance
organization, a limited health service organization, a dental
service plan corporation, a health services plan corporation,
a voluntary health services plan, or any other entity
providing a plan of dental insurance, dental benefits, or
dental health care services.
"Portal" means a website or reasonably similar method of
sharing information that: (i) is compliant with the federal
Health Insurance Portability and Accountability Act of 1996
and the regulations promulgated thereunder, and (ii) provides
resources and information to dental care providers and
subscribers.
(Source: P.A. 102-146, eff. 7-23-21.)
(215 ILCS 111/20)

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Sec. 20. Uniform electronic claims and eligibility
transactions required.
(a) Beginning January 1, 2027 2026, 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 except as
provided in this Act.
(b) All dental plan carriers and dental care providers
must exchange claims and eligibility information
electronically using the standard electronic data interchange
transactions for claims submissions, payments, and
verification of benefits required under the Health Insurance
Portability and Accountability Act in order to be compensable
by the dental plan carrier.
(c) All dental plan carriers and dental care providers
must comply with applicable State and federal privacy and
security laws, and regulations when conducting the exchange of
information under this Act.
(Source: P.A. 102-146, eff. 7-23-21; 103-705, eff. 7-19-24.)
(215 ILCS 111/25)
Sec. 25. Rules; modification of rules.
(a) The Department may shall adopt rules as necessary to
implement this Act and may establish further exemptions to
this Act by rule.
(b) A dental plan carrier or dental care provider may not

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add to or modify the uniform electronic claims and eligibility
requirements adopted by the Department.
(Source: P.A. 102-146, eff. 7-23-21.)
(215 ILCS 111/30 new)
Sec. 30. Exemptions.
(a) Notwithstanding any other provision of this Act, a
dental care provider shall not be required to submit claims
electronically under any of the following circumstances:
(1) There is a temporary technological event, due to
unforeseen practice disruptions, including, but not
limited to, natural disasters, physical damage to the
practice, or damage to the data system that prevents a
claim from being submitted electronically for more than 14
days.
(2) The dental care provider plans to retire prior to
January 1, 2031.
(3) A dental care provider works less than 20 hours
per week and is a solo practitioner.
(4) The dental care provider is a dental care provider
who is temporarily operating a practice for another dental
care provider who is unable to practice.
(b) A dental care provider who is exempted from filing
claims electronically under this Section shall file a form
with the Department indicating the applicable exemption. The
Department shall provide the form no later than January 1,

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2027.
(c) Any dental care provider that starts a dental care
practice or purchases a practice and who was previously
exempted from the requirements of this Act shall have 2 years
from the date the practice is started or purchased to comply
with this Act.
(215 ILCS 111/35 new)
Sec. 35. Eligibility and benefit verification portal.
(a) Each dental plan carrier shall establish a portal as
described in this Section and shall include information about
each type of subscription contract that is sufficient to allow
subscribers and dental care providers to determine the covered
services under each subscription contract and the payment or
reimbursement amounts for those covered services at the
procedure level. The information in the portal shall include
the following, as appropriate:
(1) Effective date of plan.
(2) Termination date of plan.
(3) Coordination of benefits; standard or
non-duplicating.
(4) Claim address.
(5) Payer identification.
(6) Covered services.
(7) Whether a deductible applies and to which
services.

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(8) Remaining deductible: family.
(9) Remaining deductible: individual.
(10) In-network coinsurance percentage.
(11) Out-of-network coinsurance percentage.
(12) Remaining plan maximum.
(13) Remaining lifetime maximum, if applicable.
(14) Previous 12 months of claim payments applied to
the member's annual maximum or deductible to help
determine if a benefit has been used outside of the
primary office.
(15) Age limitation.
(16) Frequency limit by time period.
(17) Frequency limit by tooth number.
(18) Next available service date or previous service
dates based on any frequency limit due to prior treatment
history or added custom benefits, such as medical
conditions and roll-over.
(19) Number of quads benefited per visit if a specific
benefit limitation exists that may limit the number of
quads treated and services rendered per visit.
(20) Waiting period due to preexisting condition or
missing tooth limitation.
(21) Prior authorization requirements.
(22) A comprehensive list (or procedure code level
lookup tool) of all current American Dental Association
CDT Codes stating if they are covered, the percentage of

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coverage, and if there are any conditions that preclude
coverage.
(b) At minimum, the portal shall provide current and
accurate real-time benefit eligibility and benefits
information. It is the responsibility of the dental plan
carrier to ensure patient eligibility and benefits reporting
is timely and accurate.
(c) A dental plan carrier must ensure that the portal:
(1) is compliant with the federal Health Insurance
Portability and Accountability Act of 1996 and the
regulations promulgated thereunder and allows dental care
providers to submit claims electronically and directly to
the dental plan carrier. The portal shall be provided free
of charge to the dental care provider;
(2) accepts attachments, including, but not limited
to, x-rays and other supporting information for claims, in
an electronic format with the initial electronic claim's
submission and any further submissions thereafter; and
(3) offers remittance advice with the corresponding
payment that outlines individually per claim: the name of
the patient; the date of service; the service code or, if
no service code is available, a service description; the
amount being paid; the claim number; and other identifying
claim information found on an explanation of benefits
form.

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(215 ILCS 111/40 new)
Sec. 40. Payment. Nothing in this Act requires a dental
care provider to only accept electronic payment from a dental
plan carrier.
Section 99. Effective date. This Act takes effect upon
becoming law, except that Sections 30, 35, and 40 of the
Uniform Electronic Transactions in Dental Care Billing Act
take effect January 1, 2027.".