Illinois § 35

§ 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. (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 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. (Source: P.A. 104-203, eff. 1-1-27.)