Section 140.55  Electronic Data Interchange Service

a)         Definitions

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

1)         "Batch Mode" is any request other than a "real time mode" request. The Department will respond to a "batch mode" request within 24 hours.

2)         "Medical Provider" is a provider of medical services who is enrolled with the Department to render services under any healthcare program administered by the Department.

3)         "Real Time Mode" is a request for eligibility verification for a single individual, or a request for claims status for a specific claim from a trading partner, to which the Department will respond as immediately as possible.

4)         "Recipient" is an individual eligible to receive services through any healthcare program administered by the Department.

5)         "Subscriber" is a medical provider or the agent of a medical provider who executes a contract with a trading partner to participate in the EDI service.

6)         "Trading Partner" is an entity that has successfully completed the EDI trading partner application process and executed an agreement with the Department to utilize the Department's EDI service.

b)         Electronic Data Interchange (EDI) Service

A new Electronic Data Interchange process will offer a HIPAA compliant means for trading partners to verify recipient eligibility (real time and batch mode), submit medical claims (batch mode only) and check medical claim status (real time and batch mode).  This information will be made available to medical providers through Department approved trading partners.  Trading partners are responsible for marketing the EDI service to medical providers.  Direct access to the EDI service will be made available through Department prescribed methods.  Only Department approved trading partners and their subscribing medical providers are authorized to access information provided through the EDI service, except as may be approved through subsection (e)(4).

c)         Recipient Eligibility Verification (REV) System Contract Termination

The REV system (see Section 5-1.2 of the Public Aid Code) offered on-line Medicaid eligibility information and claims history information to subscribers through REV contractors.  All REV vendor contracts that have not been terminated are terminated effective June 30, 2013.  Any REV vendor who had a contract with the Department that has terminated must apply to become a trading partner under subsection (d).

d)         Eligibility Requirements for Trading Partners

In order to be qualified to participate in the service, a trading partner must:

1)         Submit a Department prescribed application to the Department and execute an agreement with the Department. The agreement will establish the amount of reimbursement the trading partner will pay to the Department for real time mode and batch mode requests.  The agreement will also provide that the provider or trading partner will execute a written contract with each subscriber prior to any exchange of data with that subscriber;

2)         Agree to access data through one or more high speed data transmission circuits determined by the Department to be compatible with current technology and operating needs.  Current compatible high speed data transmission circuits shall be identified as part of the information provided to applicants who request the application from the Department.  Updates to technology, operating needs or transmission circuits will be provided to existing trading partners via electronic communication at least 30 days before usage is required;

3)         Treat all information, including information relating to recipients and medical providers obtained under the agreement with the Department as confidential information pursuant to the Public Aid Code [305 ILCS 5] and federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (42 CFR 160, 162 and 164);

4)         Provide data to subscribers 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 electronic communication protocols;

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

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

B)        Advances money to a medical provider for accounts receivable that the medical 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.

e)         Subscriber Contracts

The trading partner 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, submission of medical claims, and providing claims history information when 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 the subscriber or any recipient who is aggrieved by the actions of any party under the contract;

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

4)         A third party who is not qualified as a subscriber may be granted access to the EDI service through a trading partner only with prior approval of the Department;

5)         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 [305 ILCS 5] and federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (42 CFR 160, 162 and 164); and

6)         The subscriber will certify 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 program, nor are any of the above currently under sanction for, or serving a sentence for, conviction of any Medicaid or Medicare program offenses.

f)         Charges for EDI Services

1)         Reimbursement rates for real time mode and batch mode requests from a trading partner will be established in the agreement between the trading partner and the Department.

2)         Charges to the subscribers are made in accordance with the fee schedule and provisions specified in the contract between the trading partner and subscriber.

(Source:  Amended at 38 Ill. Reg. 4330, effective January 29, 2014)