IL SB3114: TRANSPARENCY IN DOWNCODING ACT

In one paragraph

The Transparency in Downcoding Act regulates how health care payors reduce the billing code on medical claims. Section 15 prohibits a payor from implementing any policy or using any algorithm or other automated process, system or tool that bypasses evaluation of the information submitted by the billing health care professional in order to downcode a claim. Payors may use automated processes to flag claims that may justify downcoding under AMA CPT coding guidelines, but every downcoding determination must be made or reviewed by a natural person. The Act applies to policies issued, amended, delivered or renewed on or after January 1, 2028, and is a limit on home rule powers.

Plain-English summary, written with AI assistance. The official text controls.

What it means for business

Insurers and claims processors that use automated claim-editing software must keep human reviewers in the downcoding loop and cannot rely on fully automated downcoding.

Key provisions

1. 1Bans algorithms or automated tools that downcode claims without evaluating provider-submitted information
2. 2Automated tools may only flag claims for possible downcoding under CPT guidelines
3. 3A natural person must make or review every downcoding decision
4. 4Applies to policies issued or renewed on or after January 1, 2028

Latest legislative action

Jul 10, 2026. Governor Approved July 10, 2026. Effective Date January 1, 2028. Public Act 104-0568.

Sponsors (showing 5 of 34)

Amendments (2)

• Senate Amendment 001 Not adopted 2026-03-26
• Senate Amendment 002 Not adopted 2026-05-06

Related and companion bills

• Illinois HB4735TRANSPARENCY IN DOWNCODING ACT