Rep. Jackie Haas
Filed: 3/25/2021
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1 | AMENDMENT TO HOUSE BILL 2832
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2 | AMENDMENT NO. ______. Amend House Bill 2832 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Public Aid Code is amended by | ||||||
5 | adding Section 5-43 and by changing Section 5-30.1 and by | ||||||
6 | adding Section 5-30.12a as follows: | ||||||
7 | (305 ILCS 5/5-30.1) | ||||||
8 | Sec. 5-30.1. Managed care protections. | ||||||
9 | (a) As used in this Section: | ||||||
10 | "Managed care organization" or "MCO" means any entity | ||||||
11 | which contracts with the Department to provide services where | ||||||
12 | payment for medical services is made on a capitated basis. | ||||||
13 | "Emergency services" include: | ||||||
14 | (1) emergency services, as defined by Section 10 of | ||||||
15 | the Managed Care Reform and Patient Rights Act; | ||||||
16 | (2) emergency medical screening examinations, as |
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1 | defined by Section 10 of the Managed Care Reform and | ||||||
2 | Patient Rights Act; | ||||||
3 | (3) post-stabilization medical services, as defined by | ||||||
4 | Section 10 of the Managed Care Reform and Patient Rights | ||||||
5 | Act; and | ||||||
6 | (4) emergency medical conditions, as defined by
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7 | Section 10 of the Managed Care Reform and Patient Rights
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8 | Act. | ||||||
9 | (b) As provided by Section 5-16.12, managed care | ||||||
10 | organizations are subject to the provisions of the Managed | ||||||
11 | Care Reform and Patient Rights Act. | ||||||
12 | (c) An MCO shall pay any provider of emergency services | ||||||
13 | that does not have in effect a contract with the contracted | ||||||
14 | Medicaid MCO. The default rate of reimbursement shall be the | ||||||
15 | rate paid under Illinois Medicaid fee-for-service program | ||||||
16 | methodology, including all policy adjusters, including but not | ||||||
17 | limited to Medicaid High Volume Adjustments, Medicaid | ||||||
18 | Percentage Adjustments, Outpatient High Volume Adjustments, | ||||||
19 | and all outlier add-on adjustments to the extent such | ||||||
20 | adjustments are incorporated in the development of the | ||||||
21 | applicable MCO capitated rates. | ||||||
22 | (d) An MCO shall pay for all post-stabilization services | ||||||
23 | as a covered service in any of the following situations: | ||||||
24 | (1) the MCO authorized such services; | ||||||
25 | (2) such services were administered to maintain the | ||||||
26 | enrollee's stabilized condition within one hour after a |
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1 | request to the MCO for authorization of further | ||||||
2 | post-stabilization services; | ||||||
3 | (3) the MCO did not respond to a request to authorize | ||||||
4 | such services within one hour; | ||||||
5 | (4) the MCO could not be contacted; or | ||||||
6 | (5) the MCO and the treating provider, if the treating | ||||||
7 | provider is a non-affiliated provider, could not reach an | ||||||
8 | agreement concerning the enrollee's care and an affiliated | ||||||
9 | provider was unavailable for a consultation, in which case | ||||||
10 | the MCO
must pay for such services rendered by the | ||||||
11 | treating non-affiliated provider until an affiliated | ||||||
12 | provider was reached and either concurred with the | ||||||
13 | treating non-affiliated provider's plan of care or assumed | ||||||
14 | responsibility for the enrollee's care. Such payment shall | ||||||
15 | be made at the default rate of reimbursement paid under | ||||||
16 | Illinois Medicaid fee-for-service program methodology, | ||||||
17 | including all policy adjusters, including but not limited | ||||||
18 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
19 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
20 | outlier add-on adjustments to the extent that such | ||||||
21 | adjustments are incorporated in the development of the | ||||||
22 | applicable MCO capitated rates. | ||||||
23 | (e) The following requirements apply to MCOs in | ||||||
24 | determining payment for all emergency services: | ||||||
25 | (1) MCOs shall not impose any requirements for prior | ||||||
26 | approval of emergency services. |
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1 | (2) The MCO shall cover emergency services provided to | ||||||
2 | enrollees who are temporarily away from their residence | ||||||
3 | and outside the contracting area to the extent that the | ||||||
4 | enrollees would be entitled to the emergency services if | ||||||
5 | they still were within the contracting area. | ||||||
6 | (3) The MCO shall have no obligation to cover medical | ||||||
7 | services provided on an emergency basis that are not | ||||||
8 | covered services under the contract. | ||||||
9 | (4) The MCO shall not condition coverage for emergency | ||||||
10 | services on the treating provider notifying the MCO of the | ||||||
11 | enrollee's screening and treatment within 10 days after | ||||||
12 | presentation for emergency services. | ||||||
13 | (5) The determination of the attending emergency | ||||||
14 | physician, or the provider actually treating the enrollee, | ||||||
15 | of whether an enrollee is sufficiently stabilized for | ||||||
16 | discharge or transfer to another facility, shall be | ||||||
17 | binding on the MCO. The MCO shall cover emergency services | ||||||
18 | for all enrollees whether the emergency services are | ||||||
19 | provided by an affiliated or non-affiliated provider. | ||||||
20 | (6) The MCO's financial responsibility for | ||||||
21 | post-stabilization care services it has not pre-approved | ||||||
22 | ends when: | ||||||
23 | (A) a plan physician with privileges at the | ||||||
24 | treating hospital assumes responsibility for the | ||||||
25 | enrollee's care; | ||||||
26 | (B) a plan physician assumes responsibility for |
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1 | the enrollee's care through transfer; | ||||||
2 | (C) a contracting entity representative and the | ||||||
3 | treating physician reach an agreement concerning the | ||||||
4 | enrollee's care; or | ||||||
5 | (D) the enrollee is discharged. | ||||||
6 | (f) Network adequacy and transparency. | ||||||
7 | (1) The Department shall: | ||||||
8 | (A) ensure that an adequate provider network is in | ||||||
9 | place, taking into consideration health professional | ||||||
10 | shortage areas and medically underserved areas; | ||||||
11 | (B) publicly release an explanation of its process | ||||||
12 | for analyzing network adequacy; | ||||||
13 | (C) periodically ensure that an MCO continues to | ||||||
14 | have an adequate network in place; and | ||||||
15 | (D) require MCOs, including Medicaid Managed Care | ||||||
16 | Entities as defined in Section 5-30.2, to meet | ||||||
17 | provider directory requirements under Section 5-30.3. | ||||||
18 | (2) Each MCO shall confirm its receipt of information | ||||||
19 | submitted specific to physician or dentist additions or | ||||||
20 | physician or dentist deletions from the MCO's provider | ||||||
21 | network within 3 days after receiving all required | ||||||
22 | information from contracted physicians or dentists, and | ||||||
23 | electronic physician and dental directories must be | ||||||
24 | updated consistent with current rules as published by the | ||||||
25 | Centers for Medicare and Medicaid Services or its | ||||||
26 | successor agency. |
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1 | (g) Timely payment of claims. | ||||||
2 | (1) The MCO shall pay a claim within 30 days of | ||||||
3 | receiving a claim that contains all the essential | ||||||
4 | information needed to adjudicate the claim. | ||||||
5 | (2) The MCO shall notify the billing party of its | ||||||
6 | inability to adjudicate a claim within 30 days of | ||||||
7 | receiving that claim. | ||||||
8 | (3) The MCO shall pay a penalty for any claims not | ||||||
9 | timely paid at an interest rate of 9%, annually, | ||||||
10 | compounded semiannually, from the date payment was | ||||||
11 | required to be made to the date of the late payment that is | ||||||
12 | at least equal to the timely payment interest penalty | ||||||
13 | imposed under Section 368a of the Illinois Insurance Code | ||||||
14 | for any claims not timely paid . | ||||||
15 | (A) When an MCO is required to pay a timely payment | ||||||
16 | interest penalty to a provider, the MCO must calculate | ||||||
17 | and pay the timely payment interest penalty that is | ||||||
18 | due to the provider within 30 days after the payment of | ||||||
19 | the claim. In no event shall a provider be required to | ||||||
20 | request or apply for payment of any owed timely | ||||||
21 | payment interest penalties. | ||||||
22 | (B) Such payments shall be reported separately | ||||||
23 | from the claim payment for services rendered to the | ||||||
24 | MCO's enrollee and clearly identified as interest | ||||||
25 | payments. | ||||||
26 | (4)(A) The Department shall require MCOs to expedite |
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1 | payments to providers identified on the Department's | ||||||
2 | expedited provider list, determined in accordance with 89 | ||||||
3 | Ill. Adm. Code 140.71(b), on a schedule at least as | ||||||
4 | frequently as the providers are paid under the | ||||||
5 | Department's fee-for-service expedited provider schedule. | ||||||
6 | (B) Compliance with the expedited provider requirement | ||||||
7 | may be satisfied by an MCO through the use of a Periodic | ||||||
8 | Interim Payment (PIP) program that has been mutually | ||||||
9 | agreed to and documented between the MCO and the provider, | ||||||
10 | and the PIP program ensures that any expedited provider | ||||||
11 | receives regular and periodic payments based on prior | ||||||
12 | period payment experience from that MCO. Total payments | ||||||
13 | under the PIP program may be reconciled against future PIP | ||||||
14 | payments on a schedule mutually agreed to between the MCO | ||||||
15 | and the provider. | ||||||
16 | (C) The Department shall share at least monthly its | ||||||
17 | expedited provider list and the frequency with which it | ||||||
18 | pays providers on the expedited list. | ||||||
19 | (g-5) Recognizing that the rapid transformation of the | ||||||
20 | Illinois Medicaid program may have unintended operational | ||||||
21 | challenges for both payers and providers: | ||||||
22 | (1) in no instance shall a medically necessary covered | ||||||
23 | service rendered in good faith, based upon eligibility | ||||||
24 | information documented by the provider, be denied coverage | ||||||
25 | or diminished in payment amount if the eligibility or | ||||||
26 | coverage information available at the time the service was |
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1 | rendered is later found to be inaccurate in the assignment | ||||||
2 | of coverage responsibility between MCOs or the | ||||||
3 | fee-for-service system, except for instances when an | ||||||
4 | individual is deemed to have not been eligible for | ||||||
5 | coverage under the Illinois Medicaid program; and | ||||||
6 | (2) the Department shall, by December 31, 2016, adopt | ||||||
7 | rules establishing policies that shall be included in the | ||||||
8 | Medicaid managed care policy and procedures manual | ||||||
9 | addressing payment resolutions in situations in which a | ||||||
10 | provider renders services based upon information obtained | ||||||
11 | after verifying a patient's eligibility and coverage plan | ||||||
12 | through either the Department's current enrollment system | ||||||
13 | or a system operated by the coverage plan identified by | ||||||
14 | the patient presenting for services: | ||||||
15 | (A) such medically necessary covered services | ||||||
16 | shall be considered rendered in good faith; | ||||||
17 | (B) such policies and procedures shall be | ||||||
18 | developed in consultation with industry | ||||||
19 | representatives of the Medicaid managed care health | ||||||
20 | plans and representatives of provider associations | ||||||
21 | representing the majority of providers within the | ||||||
22 | identified provider industry; and | ||||||
23 | (C) such rules shall be published for a review and | ||||||
24 | comment period of no less than 30 days on the | ||||||
25 | Department's website with final rules remaining | ||||||
26 | available on the Department's website. |
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1 | The rules on payment resolutions shall include, but not be | ||||||
2 | limited to: | ||||||
3 | (A) the extension of the timely filing period; | ||||||
4 | (B) retroactive prior authorizations; and | ||||||
5 | (C) guaranteed minimum payment rate of no less than | ||||||
6 | the current, as of the date of service, fee-for-service | ||||||
7 | rate, plus all applicable add-ons, when the resulting | ||||||
8 | service relationship is out of network. | ||||||
9 | The rules shall be applicable for both MCO coverage and | ||||||
10 | fee-for-service coverage. | ||||||
11 | If the fee-for-service system is ultimately determined to | ||||||
12 | have been responsible for coverage on the date of service, the | ||||||
13 | Department shall provide for an extended period for claims | ||||||
14 | submission outside the standard timely filing requirements. | ||||||
15 | (g-6) MCO Performance Metrics Report. | ||||||
16 | (1) The Department shall publish, on at least a | ||||||
17 | quarterly basis, each MCO's operational performance, | ||||||
18 | including, but not limited to, the following categories of | ||||||
19 | metrics: | ||||||
20 | (A) claims payment, including timeliness and | ||||||
21 | accuracy; | ||||||
22 | (B) prior authorizations; | ||||||
23 | (C) grievance and appeals; | ||||||
24 | (D) utilization statistics; | ||||||
25 | (E) provider disputes; | ||||||
26 | (F) provider credentialing; and |
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1 | (G) member and provider customer service. | ||||||
2 | (2) The Department shall ensure that the metrics | ||||||
3 | report is accessible to providers online by January 1, | ||||||
4 | 2017. | ||||||
5 | (3) The metrics shall be developed in consultation | ||||||
6 | with industry representatives of the Medicaid managed care | ||||||
7 | health plans and representatives of associations | ||||||
8 | representing the majority of providers within the | ||||||
9 | identified industry. | ||||||
10 | (4) Metrics shall be defined and incorporated into the | ||||||
11 | applicable Managed Care Policy Manual issued by the | ||||||
12 | Department. | ||||||
13 | (g-7) MCO claims processing and performance analysis. In | ||||||
14 | order to monitor MCO payments to hospital providers, pursuant | ||||||
15 | to this amendatory Act of the 100th General Assembly, the | ||||||
16 | Department shall post an analysis of MCO claims processing and | ||||||
17 | payment performance on its website every 6 months. Such | ||||||
18 | analysis shall include a review and evaluation of a | ||||||
19 | representative sample of hospital claims that are rejected and | ||||||
20 | denied for clean and unclean claims and the top 5 reasons for | ||||||
21 | such actions and timeliness of claims adjudication, which | ||||||
22 | identifies the percentage of claims adjudicated within 30, 60, | ||||||
23 | 90, and over 90 days, and the dollar amounts associated with | ||||||
24 | those claims. The Department shall post the contracted claims | ||||||
25 | report required by HealthChoice Illinois on its website every | ||||||
26 | 3 months. |
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1 | (g-8) Dispute resolution process. The Department shall | ||||||
2 | maintain a provider complaint portal through which a provider | ||||||
3 | can submit to the Department unresolved disputes with an MCO. | ||||||
4 | An unresolved dispute means an MCO's decision that denies in | ||||||
5 | whole or in part a claim for reimbursement to a provider for | ||||||
6 | health care services rendered by the provider to an enrollee | ||||||
7 | of the MCO with which the provider disagrees. Disputes shall | ||||||
8 | not be submitted to the portal until the provider has availed | ||||||
9 | itself of the MCO's internal dispute resolution process. | ||||||
10 | Disputes that are submitted to the MCO internal dispute | ||||||
11 | resolution process may be submitted to the Department of | ||||||
12 | Healthcare and Family Services' complaint portal no sooner | ||||||
13 | than 30 days after submitting to the MCO's internal process | ||||||
14 | and not later than 30 days after the unsatisfactory resolution | ||||||
15 | of the internal MCO process or 60 days after submitting the | ||||||
16 | dispute to the MCO internal process. Multiple claim disputes | ||||||
17 | involving the same MCO may be submitted in one complaint, | ||||||
18 | regardless of whether the claims are for different enrollees, | ||||||
19 | when the specific reason for non-payment of the claims | ||||||
20 | involves a common question of fact or policy. Within 10 | ||||||
21 | business days of receipt of a complaint, the Department shall | ||||||
22 | present such disputes to the appropriate MCO, which shall then | ||||||
23 | have 30 days to issue its written proposal to resolve the | ||||||
24 | dispute. The Department may grant one 30-day extension of this | ||||||
25 | time frame to one of the parties to resolve the dispute. If the | ||||||
26 | dispute remains unresolved at the end of this time frame or the |
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1 | provider is not satisfied with the MCO's written proposal to | ||||||
2 | resolve the dispute, the provider may, within 30 days, request | ||||||
3 | the Department to review the dispute and make a final | ||||||
4 | determination. Within 30 days of the request for Department | ||||||
5 | review of the dispute, both the provider and the MCO shall | ||||||
6 | present all relevant information to the Department for | ||||||
7 | resolution and make individuals with knowledge of the issues | ||||||
8 | available to the Department for further inquiry if needed. | ||||||
9 | Within 30 days of receiving the relevant information on the | ||||||
10 | dispute, or the lapse of the period for submitting such | ||||||
11 | information, the Department shall issue a written decision on | ||||||
12 | the dispute based on contractual terms between the provider | ||||||
13 | and the MCO, contractual terms between the MCO and the | ||||||
14 | Department of Healthcare and Family Services and applicable | ||||||
15 | Medicaid policy. The decision of the Department shall be | ||||||
16 | final. By January 1, 2020, the Department shall establish by | ||||||
17 | rule further details of this dispute resolution process. | ||||||
18 | Disputes between MCOs and providers presented to the | ||||||
19 | Department for resolution are not contested cases, as defined | ||||||
20 | in Section 1-30 of the Illinois Administrative Procedure Act, | ||||||
21 | conferring any right to an administrative hearing. | ||||||
22 | (g-9)(1) The Department shall publish annually on its | ||||||
23 | website a report on the calculation of each managed care | ||||||
24 | organization's medical loss ratio showing the following: | ||||||
25 | (A) Premium revenue, with appropriate adjustments. | ||||||
26 | (B) Benefit expense, setting forth the aggregate |
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1 | amount spent for the following: | ||||||
2 | (i) Direct paid claims. | ||||||
3 | (ii) Subcapitation payments. | ||||||
4 | (iii)
Other claim payments. | ||||||
5 | (iv)
Direct reserves. | ||||||
6 | (v)
Gross recoveries. | ||||||
7 | (vi)
Expenses for activities that improve health | ||||||
8 | care quality as allowed by the Department. | ||||||
9 | (2) The medical loss ratio shall be calculated consistent | ||||||
10 | with federal law and regulation following a claims runout | ||||||
11 | period determined by the Department. | ||||||
12 | (g-10)(1) "Liability effective date" means the date on | ||||||
13 | which an MCO becomes responsible for payment for medically | ||||||
14 | necessary and covered services rendered by a provider to one | ||||||
15 | of its enrollees in accordance with the contract terms between | ||||||
16 | the MCO and the provider. The liability effective date shall | ||||||
17 | be the later of: | ||||||
18 | (A) The execution date of a network participation | ||||||
19 | contract agreement. | ||||||
20 | (B) The date the provider or its representative | ||||||
21 | submits to the MCO the complete and accurate standardized | ||||||
22 | roster form for the provider in the format approved by the | ||||||
23 | Department. | ||||||
24 | (C) The provider effective date contained within the | ||||||
25 | Department's provider enrollment subsystem within the | ||||||
26 | Illinois Medicaid Program Advanced Cloud Technology |
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1 | (IMPACT) System. | ||||||
2 | (2) The standardized roster form may be submitted to the | ||||||
3 | MCO at the same time that the provider submits an enrollment | ||||||
4 | application to the Department through IMPACT. | ||||||
5 | (3) By October 1, 2019, the Department shall require all | ||||||
6 | MCOs to update their provider directory with information for | ||||||
7 | new practitioners of existing contracted providers within 30 | ||||||
8 | days of receipt of a complete and accurate standardized roster | ||||||
9 | template in the format approved by the Department provided | ||||||
10 | that the provider is effective in the Department's provider | ||||||
11 | enrollment subsystem within the IMPACT system. Such provider | ||||||
12 | directory shall be readily accessible for purposes of | ||||||
13 | selecting an approved health care provider and comply with all | ||||||
14 | other federal and State requirements. | ||||||
15 | (g-11) The Department shall work with relevant | ||||||
16 | stakeholders on the development of operational guidelines to | ||||||
17 | enhance and improve operational performance of Illinois' | ||||||
18 | Medicaid managed care program, including, but not limited to, | ||||||
19 | improving provider billing practices, reducing claim | ||||||
20 | rejections and inappropriate payment denials, and | ||||||
21 | standardizing processes, procedures, definitions, and response | ||||||
22 | timelines, with the goal of reducing provider and MCO | ||||||
23 | administrative burdens and conflict. The Department shall | ||||||
24 | include a report on the progress of these program improvements | ||||||
25 | and other topics in its Fiscal Year 2020 annual report to the | ||||||
26 | General Assembly. |
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1 | (h) The Department shall not expand mandatory MCO | ||||||
2 | enrollment into new counties beyond those counties already | ||||||
3 | designated by the Department as of June 1, 2014 for the | ||||||
4 | individuals whose eligibility for medical assistance is not | ||||||
5 | the seniors or people with disabilities population until the | ||||||
6 | Department provides an opportunity for accountable care | ||||||
7 | entities and MCOs to participate in such newly designated | ||||||
8 | counties. | ||||||
9 | (i) The requirements of this Section apply to contracts | ||||||
10 | with accountable care entities and MCOs entered into, amended, | ||||||
11 | or renewed after June 16, 2014 (the effective date of Public | ||||||
12 | Act 98-651).
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13 | (j) Health care information released to managed care | ||||||
14 | organizations. A health care provider shall release to a | ||||||
15 | Medicaid managed care organization, upon request, and subject | ||||||
16 | to the Health Insurance Portability and Accountability Act of | ||||||
17 | 1996 and any other law applicable to the release of health | ||||||
18 | information, the health care information of the MCO's | ||||||
19 | enrollee, if the enrollee has completed and signed a general | ||||||
20 | release form that grants to the health care provider | ||||||
21 | permission to release the recipient's health care information | ||||||
22 | to the recipient's insurance carrier. | ||||||
23 | (Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; | ||||||
24 | 100-587, eff. 6-4-18; 101-209, eff. 8-5-19.) | ||||||
25 | (305 ILCS 5/5-30.12a new) |
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1 | Sec. 5-30.12a. Medical Electronic Data Interchange system | ||||||
2 | upgrade. By July 1, 2022, the Department of Healthcare and | ||||||
3 | Family Services shall explore the availability of and, if | ||||||
4 | reasonably available, procure technology that: (i) allows the | ||||||
5 | Department's Medical Electronic Data Interchange (MEDI) system | ||||||
6 | to update recipient eligibility and coverage information for | ||||||
7 | providers in real time; and (ii) allows the Department to | ||||||
8 | transmit updated recipient eligibility and coverage | ||||||
9 | information to managed care organizations under contract with | ||||||
10 | the Department to ensure the information contained in the MEDI | ||||||
11 | system corresponds with the information maintained by managed | ||||||
12 | care organizations in their web-based provider portals. | ||||||
13 | (305 ILCS 5/5-43 new) | ||||||
14 | Sec. 5-43. MCO post-payment audit; time period limitation. | ||||||
15 | Notwithstanding any provision of this Code to the contrary, in | ||||||
16 | order to recover an overpayment by recoupment or offset of | ||||||
17 | future payments, a managed care organization's post-payment | ||||||
18 | audit of any claim submitted by a provider must be completed no | ||||||
19 | later than 2 years after the claim's payment date. The 2-year | ||||||
20 | time limit does not apply to claims that are (i) submitted | ||||||
21 | fraudulently, (ii) known, or should have been known, by the | ||||||
22 | provider to be a pattern of inappropriate billing according to | ||||||
23 | standard provider billing practices, or (iii) subject to any | ||||||
24 | federal law or regulation that permits post-payment audits | ||||||
25 | beyond 2 years.
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1 | Section 99. Effective date. This Act takes effect upon | ||||||
2 | becoming law.".
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