Section 140.55  Recipient Eligibility Verification (REV) System

a)         REV System Description

The REV system was created under Public Act 88-554 and offers on-line Medicaid eligibility information and claims history information to subscribers.  This information is provided to subscribers through contractors who have entered into a contract with the Department. The contractors are responsible for marketing the system to providers.  Services will be made available through leased lines between the contractors and the State.  Upon availability of REV contractors in a geographic area, only contractors and subscribers participating in the REV system are authorized to access information provided through the REV system.

b)         Definitions

As used in this Section, unless the context requires otherwise:

1)         Contractors are those entities having successfully completed the Request for Proposal (RFP) process and executed a contract with the Department to provide services under the REV system.

2)         Providers are providers of medical services who are enrolled with the Department to render services under the Medicaid program.

3)         Subscribers are medical providers who are enrolled in the Medicaid program or are the provider's agent and who execute a contract with a contractor to participate in the REV system.

c)         Eligible Contractors

In order to be qualified to participate in the system, the contractor must:

1)         Submit a proposal acceptable to the Department and execute a contract with the Department.  Under this contract, the contractor must agree to execute a written contract with each subscriber prior to any exchange of data with that subscriber and only after the contractor has received prior approval from the State of the model subscriber contract language;

2)         By the end of the first 12 months of the contract, handle a minimum number of subscribers or transactions per month as determined by the Department;

3)         Agree to access data through one or more high speed data transmission circuits as determined by the Department to be compatible with current technology and operating needs;

4)         Treat all information, including information relating to recipients and providers obtained by the contractor through performance while under the contract with the Department, as confidential information pursuant to the Public Aid Code;

5)         Provide data through a system designed to be flexible to meet each subscriber's needs as well as meeting the following specific requirements:

A)        Support various means of telecommunication that are commonly available for use by the subscriber; and

B)        Be compatible with the State of Illinois Department of Central Management Services' current telecommunications operating environment;

6)         Certify that it is neither an individual nor an organization that:

A)        Furnishes statements or bills and receives payment in the name of the providers; or

B)        Advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the individual or organization for an added fee or a deduction of the portion of the accounts receivable.

d)         Subscriber Contracts

The contractor must agree that all contracts with subscribers provide that:

1)         Access to the system shall be restricted to the sole purpose of verification of medical assistance eligibility and providing claims history information where a subscriber is requesting payment information for medical services rendered to a recipient;

2)         The subscriber indemnifies and holds harmless the State, its agents and employees from any and all claims by such subscriber or any recipient who is aggrieved by the actions of any party under the contract;

3)         The subscriber is an enrolled Medicaid provider or the provider's agent;

4)         The fees charged to subscribers must be reasonable;

5)         Any other third party may be granted access to the system only with prior approval of the State;

6)         All information, including information relating to recipients and providers obtained by the subscriber through performance under contract with the contractor, is treated as confidential information pursuant to the Public Aid Code; and

7)         The subscriber certifies that neither it, nor any employees, partners, officers or shareholders of the subscriber, are currently barred, suspended or terminated from participation in the Medicaid or Medicare programs, nor are any of the above currently under sanction for, or serving a sentence for, conviction of any Medicaid or Medicare program offenses.

e)         Charges for System Services

1)         Charges to contractors will be established in the contract between the contractor and the Department.

2)         Charges to the subscribers are made in accordance with the fee schedule and provisions specified in the contractor's and subscriber's contract.

f)          Required Subscriber Information

The following recipient information must be made available to the subscriber:

1)         Medicaid eligibility status for service date(s);

2)         Date of birth;

3)         Medicare eligibility;

4)         HMO enrollment data;

5)         Recipient restriction status;

6)         Spend-down status;

7)         Recipient claims history information; and

8)         Third Party Liability (TPL) information, including:

A)        Carrier name and address;

B)        Coverage types;

C)        Policyholder name and address;

D)        Policy number;

E)         Group number;

F)         Coverage date; and

G)        Coverage termination date.

(Source:  Added at 20 Ill. Reg. 6929, effective May 6, 1996)