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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Public Aid Code is amended by | ||||||||||||||||||||||||||
5 | changing Section 5-30.1 and by adding Section 5-30.11 as | ||||||||||||||||||||||||||
6 | 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 which | ||||||||||||||||||||||||||
11 | contracts with the Department to provide services where payment | ||||||||||||||||||||||||||
12 | for medical services is made on a capitated basis. | ||||||||||||||||||||||||||
13 | "Emergency services" include: | ||||||||||||||||||||||||||
14 | (1) emergency services, as defined by Section 10 of the | ||||||||||||||||||||||||||
15 | Managed Care Reform and Patient Rights Act; | ||||||||||||||||||||||||||
16 | (2) emergency medical screening examinations, as | ||||||||||||||||||||||||||
17 | defined by Section 10 of the Managed Care Reform and | ||||||||||||||||||||||||||
18 | Patient Rights Act; | ||||||||||||||||||||||||||
19 | (3) post-stabilization medical services, as defined by | ||||||||||||||||||||||||||
20 | Section 10 of the Managed Care Reform and Patient Rights | ||||||||||||||||||||||||||
21 | Act; and | ||||||||||||||||||||||||||
22 | (4) emergency medical conditions, as defined by
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23 | Section 10 of the Managed Care Reform and Patient Rights
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1 | Act. | ||||||
2 | "Claim Rejection" means a claim which is not correctly | ||||||
3 | formatted and therefore cannot be processed when submitted for | ||||||
4 | payment due to errors that cannot be corrected by the MCO. | ||||||
5 | "Claim payment rate adjustment" means any retroactive | ||||||
6 | change to the rate or rates of payment from an MCO to a | ||||||
7 | provider that results in a change in the total payment to the | ||||||
8 | provider from the amount originally paid to the provider for | ||||||
9 | the service. Such rate adjustments shall include, but not be | ||||||
10 | limited to, either positive or negative rate adjustments, | ||||||
11 | incentive payments, bonuses, or settlement adjustments. | ||||||
12 | "Claim recoupment adjustment" means any reduction to the | ||||||
13 | initial final claim payment amount that is applied as an | ||||||
14 | off-set for the purpose of recouping amounts due from the | ||||||
15 | provider and owed to the MCO or the Department. All recoupment | ||||||
16 | adjustments must be clearly and separately noted on any | ||||||
17 | remittance advice when paying the provider. The rate-based | ||||||
18 | total payment amount must be clearly and separately delineated | ||||||
19 | from any applied recoupment adjustment. | ||||||
20 | "Claim denial" means a determination of nonpayment by the | ||||||
21 | MCO of a properly formatted claim for services rendered by the | ||||||
22 | provider. "Denial" means the MCO has determined that it has no | ||||||
23 | liability under the Medical Assistance Program, the MCO | ||||||
24 | contract with the Department, an existing contract with the | ||||||
25 | provider, or other applicable provisions of law. Examples of an | ||||||
26 | acceptable denial include, but are not limited to: (i) the |
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1 | determination that the service rendered is not covered under | ||||||
2 | the Medical Assistance Program, the MCO contract with the | ||||||
3 | Department, an existing contract with the provider, or other | ||||||
4 | applicable provisions of law; (ii) the beneficiary listed on | ||||||
5 | the claim is not enrolled in the MCO; or (iii) a contractually | ||||||
6 | required service authorization was not requested by the | ||||||
7 | provider. | ||||||
8 | "Service authorization" means any service for which an MCO | ||||||
9 | requires a provider, as specified in its service agreement, | ||||||
10 | contract, or handbook, to submit a request for medical review | ||||||
11 | authorizing the service, either prior to, concurrent with, or | ||||||
12 | following the delivery of the service. Service authorization | ||||||
13 | includes, but is not limited to, the following terms: | ||||||
14 | precertification, preadmission review, pre-service review, | ||||||
15 | prior authorization, prior approval, notification, concurrent | ||||||
16 | review, retrospective review, prepayment review, and post | ||||||
17 | payment review. | ||||||
18 | (b) As provided by Section 5-16.12, managed care | ||||||
19 | organizations are subject to the provisions of the Managed Care | ||||||
20 | Reform and Patient Rights Act. | ||||||
21 | (c) An MCO shall pay any provider of emergency services | ||||||
22 | that does not have in effect a contract with the contracted | ||||||
23 | Medicaid MCO. The default rate of reimbursement shall be the | ||||||
24 | rate paid under Illinois Medicaid fee-for-service program | ||||||
25 | methodology, including all policy adjusters, including but not | ||||||
26 | limited to Medicaid High Volume Adjustments, Medicaid |
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1 | Percentage Adjustments, Outpatient High Volume Adjustments, | ||||||
2 | and all outlier add-on adjustments to the extent such | ||||||
3 | adjustments are incorporated in the development of the | ||||||
4 | applicable MCO capitated rates. | ||||||
5 | (d) An MCO shall pay for all post-stabilization services as | ||||||
6 | a covered service in any of the following situations: | ||||||
7 | (1) the MCO authorized such services; | ||||||
8 | (2) such services were administered to maintain the | ||||||
9 | enrollee's stabilized condition within one hour after a | ||||||
10 | request to the MCO for authorization of further | ||||||
11 | post-stabilization services; | ||||||
12 | (3) the MCO did not respond to a request to authorize | ||||||
13 | such services within one hour; | ||||||
14 | (4) the MCO could not be contacted; or | ||||||
15 | (5) the MCO and the treating provider, if the treating | ||||||
16 | provider is a non-affiliated provider, could not reach an | ||||||
17 | agreement concerning the enrollee's care and an affiliated | ||||||
18 | provider was unavailable for a consultation, in which case | ||||||
19 | the MCO
must pay for such services rendered by the treating | ||||||
20 | non-affiliated provider until an affiliated provider was | ||||||
21 | reached and either concurred with the treating | ||||||
22 | non-affiliated provider's plan of care or assumed | ||||||
23 | responsibility for the enrollee's care. Such payment shall | ||||||
24 | be made at the default rate of reimbursement paid under | ||||||
25 | Illinois Medicaid fee-for-service program methodology, | ||||||
26 | including all policy adjusters, including but not limited |
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1 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
2 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
3 | outlier add-on adjustments to the extent that such | ||||||
4 | adjustments are incorporated in the development of the | ||||||
5 | applicable MCO capitated rates. | ||||||
6 | (e) The following requirements apply to MCOs in determining | ||||||
7 | payment for all emergency services: | ||||||
8 | (1) MCOs shall not impose any requirements for prior | ||||||
9 | approval of emergency services. | ||||||
10 | (2) The MCO shall cover emergency services provided to | ||||||
11 | enrollees who are temporarily away from their residence and | ||||||
12 | outside the contracting area to the extent that the | ||||||
13 | enrollees would be entitled to the emergency services if | ||||||
14 | they still were within the contracting area. | ||||||
15 | (3) The MCO shall have no obligation to cover medical | ||||||
16 | services provided on an emergency basis that are not | ||||||
17 | covered services under the contract. | ||||||
18 | (4) The MCO shall not condition coverage for emergency | ||||||
19 | services on the treating provider notifying the MCO of the | ||||||
20 | enrollee's screening and treatment within 10 days after | ||||||
21 | presentation for emergency services. | ||||||
22 | (5) The determination of the attending emergency | ||||||
23 | physician, or the provider actually treating the enrollee, | ||||||
24 | of whether an enrollee is sufficiently stabilized for | ||||||
25 | discharge or transfer to another facility, shall be binding | ||||||
26 | on the MCO. The MCO shall cover emergency services for all |
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1 | enrollees whether the emergency services are provided by an | ||||||
2 | affiliated or non-affiliated provider. | ||||||
3 | (6) The MCO's financial responsibility for | ||||||
4 | post-stabilization care services it has not pre-approved | ||||||
5 | ends when: | ||||||
6 | (A) a plan physician with privileges at the | ||||||
7 | treating hospital assumes responsibility for the | ||||||
8 | enrollee's care; | ||||||
9 | (B) a plan physician assumes responsibility for | ||||||
10 | the enrollee's care through transfer; | ||||||
11 | (C) a contracting entity representative and the | ||||||
12 | treating physician reach an agreement concerning the | ||||||
13 | enrollee's care; or | ||||||
14 | (D) the enrollee is discharged. | ||||||
15 | (f) Network adequacy and transparency. | ||||||
16 | (1) The Department shall: | ||||||
17 | (A) ensure that an adequate provider network is in | ||||||
18 | place, taking into consideration health professional | ||||||
19 | shortage areas and medically underserved areas; | ||||||
20 | (B) publicly release an explanation of its process | ||||||
21 | for analyzing network adequacy; | ||||||
22 | (C) periodically ensure that an MCO continues to | ||||||
23 | have an adequate network in place; and | ||||||
24 | (D) require MCOs, including Medicaid Managed Care | ||||||
25 | Entities as defined in Section 5-30.2, to meet provider | ||||||
26 | directory requirements under Section 5-30.3 ; and . |
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1 | (E) require MCOs to: (i) ensure that any provider | ||||||
2 | under contract with an MCO on the date of service is | ||||||
3 | paid for any medically necessary service rendered to | ||||||
4 | any of the MCO's enrollees, regardless of inclusion on | ||||||
5 | the MCO's published and publicly available roster of | ||||||
6 | available providers; and (ii) ensure that all | ||||||
7 | contracted providers are listed on an updated roster | ||||||
8 | within 7 days of entering into a contract with the MCO | ||||||
9 | and that such roster is readily accessible to all | ||||||
10 | medical assistance enrollees for purposes of selecting | ||||||
11 | an approved healthcare provider. | ||||||
12 | (2) Each MCO shall confirm its receipt of information | ||||||
13 | submitted specific to physician or dentist additions or | ||||||
14 | physician or dentist deletions from the MCO's provider | ||||||
15 | network within 3 days after receiving all required | ||||||
16 | information from contracted physicians or dentists, and | ||||||
17 | electronic physician and dental directories must be | ||||||
18 | updated consistent with current rules as published by the | ||||||
19 | Centers for Medicare and Medicaid Services or its successor | ||||||
20 | agency. | ||||||
21 | (g) Timely payment of claims. | ||||||
22 | (1) The MCO shall pay a claim within 30 days of | ||||||
23 | receiving a claim that contains all the essential | ||||||
24 | information needed to adjudicate the claim. | ||||||
25 | (A) The Department shall develop a single standard | ||||||
26 | list of all additional clinical information, beyond |
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1 | the standard uniform national billing requirements, | ||||||
2 | which shall be considered essential information that | ||||||
3 | may be requested from a hospital to adjudicate a claim. | ||||||
4 | An MCO shall not require a hospital to provide | ||||||
5 | information to adjudicate a claim, other than | ||||||
6 | information stated on the standard list developed by | ||||||
7 | the Department. | ||||||
8 | (B) The Department shall include the standard list | ||||||
9 | of essential information in the agreement between each | ||||||
10 | MCO and the Department and the Department shall publish | ||||||
11 | the standard list of essential information on its | ||||||
12 | website. | ||||||
13 | (C) The standard list of essential information | ||||||
14 | shall be developed by the Department, in consultation | ||||||
15 | with MCOs and the statewide association representing a | ||||||
16 | majority of hospitals in the State. The Department may | ||||||
17 | update the standard list of all essential information | ||||||
18 | to adjudicate a claim no more frequently than annually. | ||||||
19 | (2) If an MCO requires information from the standard | ||||||
20 | list of essential information to adjudicate a claim, it | ||||||
21 | must request this additional information within 5 business | ||||||
22 | days of receipt of the claim. The MCO shall notify the | ||||||
23 | billing party of its inability to adjudicate a claim within | ||||||
24 | 30 days of receiving that claim. | ||||||
25 | (A) Under no circumstance shall a provider be | ||||||
26 | required to submit additional information, justifying |
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1 | medical necessity, for a service which has previously | ||||||
2 | received a service authorization by the MCO or its | ||||||
3 | agent. All services rendered in good faith by a | ||||||
4 | provider based on a service authorization from an MCO | ||||||
5 | or its agent shall be timely paid by the MCO at a rate | ||||||
6 | associated with the service authorized and consistent | ||||||
7 | with the contractual agreement between the MCO and the | ||||||
8 | provider or, if there is no contractual agreement, at a | ||||||
9 | rate otherwise required by law. | ||||||
10 | (B) Any request for additional information, | ||||||
11 | necessary for the final adjudication of payment, may | ||||||
12 | only temporarily suspend the 30-day timely payment | ||||||
13 | requirement from the date additional information is | ||||||
14 | requested from the provider until the date it is | ||||||
15 | received from the provider. | ||||||
16 | (3) The MCO shall pay a penalty that is at least equal | ||||||
17 | to the timely payment interest penalty imposed under the | ||||||
18 | Illinois Insurance Code for any claims not timely paid. | ||||||
19 | (A) When an MCO is required to pay a timely payment | ||||||
20 | interest penalty to a provider, the MCO must | ||||||
21 | automatically calculate and pay the timely payment | ||||||
22 | interest penalty that is due to the provider within 30 | ||||||
23 | days after the payment of the claim. In no event shall | ||||||
24 | a provider be required to request or apply for payment | ||||||
25 | of any owed timely payment interest penalties. | ||||||
26 | (B) A MCO shall report at the time of payment to |
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1 | each provider all timely payment interest penalty | ||||||
2 | payments made to that provider, with such payments | ||||||
3 | being reported separately from the claim payment for | ||||||
4 | services rendered to the MCO's enrollee. Timely | ||||||
5 | interest penalty payments shall not be considered a | ||||||
6 | claim payment rate adjustment, as defined in this | ||||||
7 | Section, and shall be considered separately due and | ||||||
8 | payable by the MCO to the provider. | ||||||
9 | (4) The Department shall require MCOs to expedite | ||||||
10 | payments to providers based on criteria that include, but | ||||||
11 | are not limited to: The Department may establish a process | ||||||
12 | for MCOs to expedite payments to providers based on | ||||||
13 | criteria established by the Department . | ||||||
14 | (A) At a minimum, each MCO shall ensure that | ||||||
15 | providers identified on the Department's expedited | ||||||
16 | provider list, determined in accordance with 89 Ill. | ||||||
17 | Adm. Code 140.71(b), are paid by the MCO on a schedule | ||||||
18 | at least as frequently as the providers are paid under | ||||||
19 | the Department's fee-for-service expedited provider | ||||||
20 | schedule. | ||||||
21 | (B) Compliance with the expedited provider | ||||||
22 | requirement may be satisfied by an MCO through the use | ||||||
23 | of a Periodic Interim Payment (PIP) program that has | ||||||
24 | been mutually agreed to and documented between the MCO | ||||||
25 | and the provider, if the PIP program ensures that any | ||||||
26 | expedited provider receives regular and periodic |
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1 | payments based on prior period payment experience from | ||||||
2 | that MCO. Total payments under the PIP program may be | ||||||
3 | reconciled against future PIP payments on a schedule | ||||||
4 | mutually agreed to between the MCO and the provider. | ||||||
5 | (5) The Department shall establish a single list of | ||||||
6 | standard codes, by provider industry, to identify the | ||||||
7 | reason or reasons a claim is not to be paid. The list must | ||||||
8 | include an explanation of each code and the action or | ||||||
9 | actions required by the provider to correct all errors, if | ||||||
10 | any. | ||||||
11 | (A) The Department and each MCO shall use the | ||||||
12 | standard code set and descriptions published by the | ||||||
13 | Department on the Explanation of Payment, and make | ||||||
14 | available a system which maps the standard codes and | ||||||
15 | descriptions to the applicable American National | ||||||
16 | Standard Institute codes and includes all necessary | ||||||
17 | corrective actions, if possible to move the claim, | ||||||
18 | whether submitted in electronic format or | ||||||
19 | non-electronic, to a payable status. | ||||||
20 | (B) The requirement under this Section is meant to | ||||||
21 | provide a more descriptive supplement to any required | ||||||
22 | notifications subject to the ASC X12 electronic | ||||||
23 | transaction standards adopted under the federal Health | ||||||
24 | Insurance Portability and Accountability Act. | ||||||
25 | (C) The single list of standard codes shall be | ||||||
26 | developed in consultation with industry |
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1 | representatives of the Medicaid managed care health | ||||||
2 | plans and representatives of provider associations | ||||||
3 | representing the majority of providers within the | ||||||
4 | identified provider industry. | ||||||
5 | (g-5) Recognizing that the rapid transformation of the | ||||||
6 | Illinois Medicaid program may have unintended operational | ||||||
7 | challenges for both payers and providers: | ||||||
8 | (1) in no instance shall a medically necessary covered | ||||||
9 | service rendered in good faith, based upon eligibility | ||||||
10 | information documented by the provider, be denied coverage | ||||||
11 | or diminished in payment amount if the eligibility or | ||||||
12 | coverage information available at the time the service was | ||||||
13 | rendered is later found to be inaccurate; and | ||||||
14 | (2) the Department shall, by December 31, 2016, adopt | ||||||
15 | rules establishing policies that shall be included in the | ||||||
16 | Medicaid managed care policy and procedures manual | ||||||
17 | addressing payment resolutions in situations in which a | ||||||
18 | provider renders services based upon information obtained | ||||||
19 | after verifying a patient's eligibility and coverage plan | ||||||
20 | through either the Department's current enrollment system | ||||||
21 | or a system operated by the coverage plan identified by the | ||||||
22 | patient presenting for services: | ||||||
23 | (A) such medically necessary covered services | ||||||
24 | shall be considered rendered in good faith; | ||||||
25 | (B) such policies and procedures shall be | ||||||
26 | developed in consultation with industry |
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1 | representatives of the Medicaid managed care health | ||||||
2 | plans and representatives of provider associations | ||||||
3 | representing the majority of providers within the | ||||||
4 | identified provider industry; and | ||||||
5 | (C) such rules shall be published for a review and | ||||||
6 | comment period of no less than 30 days on the | ||||||
7 | Department's website with final rules remaining | ||||||
8 | available on the Department's website. | ||||||
9 | (3) The rules on payment resolutions shall include, but | ||||||
10 | not be limited to: | ||||||
11 | (A) the extension of the timely filing period; | ||||||
12 | (B) retroactive prior authorizations; and | ||||||
13 | (C) guaranteed minimum payment rate of no less than | ||||||
14 | the current, as of the date of service, fee-for-service | ||||||
15 | rate, plus all applicable add-ons, when the resulting | ||||||
16 | service relationship is out of network. | ||||||
17 | (4) The rules shall be applicable for both MCO coverage | ||||||
18 | and fee-for-service coverage. | ||||||
19 | (g-6) MCO Performance Metrics Report. | ||||||
20 | (1) The Department shall publish, on at least a | ||||||
21 | quarterly basis, each MCO's operational performance, | ||||||
22 | including, but not limited to, the following categories of | ||||||
23 | metrics: | ||||||
24 | (A) claims payment, including timeliness and | ||||||
25 | accuracy; | ||||||
26 | (B) prior authorizations; |
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1 | (C) grievance and appeals; | ||||||
2 | (D) utilization statistics; | ||||||
3 | (E) provider disputes; | ||||||
4 | (F) provider credentialing; and | ||||||
5 | (G) member and provider customer service. | ||||||
6 | (2) The Department shall ensure that the metrics report | ||||||
7 | is accessible to providers online by January 1, 2017. | ||||||
8 | (3) The metrics shall be developed in consultation with | ||||||
9 | industry representatives of the Medicaid managed care | ||||||
10 | health plans and representatives of associations | ||||||
11 | representing the majority of providers within the | ||||||
12 | identified industry. | ||||||
13 | (4) Metrics shall be defined and incorporated into the | ||||||
14 | applicable Managed Care Policy Manual issued by the | ||||||
15 | Department. | ||||||
16 | (g-7) MCO claims processing and performance analysis. In | ||||||
17 | order to monitor MCO payments to hospital providers, pursuant | ||||||
18 | to this amendatory Act of the 100th General Assembly, the | ||||||
19 | Department shall post an analysis of MCO claims processing and | ||||||
20 | payment performance on its website every 6 months. Such | ||||||
21 | analysis shall include a review and evaluation of a | ||||||
22 | representative sample of hospital claims that are rejected and | ||||||
23 | denied for clean and unclean claims and the top 5 reasons for | ||||||
24 | such actions and timeliness of claims adjudication, which | ||||||
25 | identifies the percentage of claims adjudicated within 30, 60, | ||||||
26 | 90, and over 90 days, and the dollar amounts associated with |
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1 | those claims. The Department shall post the contracted claims | ||||||
2 | report required by HealthChoice Illinois on its website every 3 | ||||||
3 | months. | ||||||
4 | (g-8) Notwithstanding any other law, whenever the | ||||||
5 | resolution of a dispute between an MCO and a provider related | ||||||
6 | to the MCO's obligation to pay a claim results in the | ||||||
7 | determination that the recipient's coverage on the date of | ||||||
8 | service was under the Department's fee-for-service system, the | ||||||
9 | provider shall be afforded an additional 120 days from the date | ||||||
10 | of notice of such determination to submit the claim to the | ||||||
11 | Department for payment under the fee-for-service system. The | ||||||
12 | Department shall expedite the processing and adjudication of | ||||||
13 | such claims. | ||||||
14 | (A) In such instances, there shall be no dispute as | ||||||
15 | to the Department's liability under the | ||||||
16 | fee-for-service system for a validly rendered service. | ||||||
17 | (B) Any requirement of prior service authorization | ||||||
18 | by the State shall be waived in such circumstances. | ||||||
19 | (C) In such instances, if a claim for payment | ||||||
20 | derives from a transfer from one hospital to another, | ||||||
21 | resulting in continuous care by both hospitals, there | ||||||
22 | shall be no dispute in the assignment of coverage for | ||||||
23 | the service, such that if the initiating hospital | ||||||
24 | service was covered under the Department's | ||||||
25 | fee-for-service system, then the liability for the | ||||||
26 | entire claim shall remain under the Department's |
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1 | fee-for-service system. | ||||||
2 | (9-9) Notwithstanding any other provisions of law, if the | ||||||
3 | Department or an MCO requires submission of a claim for payment | ||||||
4 | in a non-electronic format, a provider shall always be afforded | ||||||
5 | a period of no less than 90 business days, as a correction | ||||||
6 | period, following any notification of rejection by either the | ||||||
7 | Department or the MCO to correct errors or omissions in the | ||||||
8 | original submission. | ||||||
9 | Under no circumstances, either by an MCO or under the | ||||||
10 | Department's fee-for-service system, shall a provider be | ||||||
11 | denied payment for failure to comply with any timely claims | ||||||
12 | submission requirements of this Code or under any existing | ||||||
13 | contract, unless the non-electronic format claim submission | ||||||
14 | occurs after the initial 180 days following the latest date of | ||||||
15 | service on the claim, or after the 90 business days correction | ||||||
16 | period following notification to the provider of rejection or | ||||||
17 | denial of payment. | ||||||
18 | (g-10) Medical necessity determination. | ||||||
19 | (1) Any MCO under contract with the Department that | ||||||
20 | requires service authorization for any service, in order | ||||||
21 | for payment to be made, must have an electronic system that | ||||||
22 | accepts and preserves electronically for both parties all | ||||||
23 | service authorization requests, related clinical | ||||||
24 | documentation, and service authorization determinations. A | ||||||
25 | transaction tracking number must be issued to the provider | ||||||
26 | at the time of the request, noting the level of care |
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1 | requested for the service authorization, and must be | ||||||
2 | transmitted to the requesting provider either | ||||||
3 | electronically or provided telephonically. | ||||||
4 | (2) A MCO must authorize or reject a request for | ||||||
5 | service authorization, submitted prior to the delivery of | ||||||
6 | the service, within 4 calendar days of the day when all | ||||||
7 | information requested by the MCO, in order to rule on the | ||||||
8 | request, has been provided. Such service authorization or | ||||||
9 | rejection must contain the transaction tracking number and | ||||||
10 | level of care being authorized or rejected. If the | ||||||
11 | enrollee's medical condition is such that a time frame of 4 | ||||||
12 | days could seriously jeopardize the enrollee's life or | ||||||
13 | health, the MCO must authorize or reject a request within | ||||||
14 | 48 hours. Time frames for authorization of | ||||||
15 | post-stabilization services are governed by subsection (d) | ||||||
16 | of this Section. If no authorization or denial is provided | ||||||
17 | within the appropriate time frame outlined in this | ||||||
18 | subsection, the request for service authorization shall be | ||||||
19 | considered approved, and the service associated with the | ||||||
20 | authorization shall be deemed payable by the MCO at the | ||||||
21 | standard contractual rate of reimbursement for the service | ||||||
22 | or as required by law. | ||||||
23 | (3) If a service authorization is given, the MCO cannot | ||||||
24 | request further clinical data for the purpose of a medical | ||||||
25 | necessity review prior to payment when a claim for the | ||||||
26 | service is received by the MCO, unless the service on the |
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1 | claim differs significantly from the service which was | ||||||
2 | approved. Unless the service is deemed to significantly | ||||||
3 | differ from the service authorized when the service | ||||||
4 | authorization was given by the MCO, the service shall be | ||||||
5 | deemed medically necessary and authorized for payment at | ||||||
6 | the rate consistent with the service initially authorized | ||||||
7 | by the MCO and shall be paid. | ||||||
8 | (4) If the service on a claim differs significantly | ||||||
9 | from the service previously approved, the provider must | ||||||
10 | have at least 30 days from receiving a request from the MCO | ||||||
11 | to submit clinical information to show medical necessity of | ||||||
12 | the service that was billed. If the clinical information | ||||||
13 | demonstrates that the billed service was medically | ||||||
14 | necessary, the claim shall be paid. | ||||||
15 | (5) If a service did not require a service | ||||||
16 | authorization under the MCO's policies, and the MCO | ||||||
17 | undertakes a medical necessity review prior to paying the | ||||||
18 | claim, the MCO must request all necessary information for | ||||||
19 | the review from the provider within 5 business days of the | ||||||
20 | receipt of the claim and the provider shall have at least | ||||||
21 | 30 business days from the receipt of the request to provide | ||||||
22 | the information requested by the MCO. | ||||||
23 | (6) Before an MCO can recover payments made based on a | ||||||
24 | post-payment audit, the MCO must give the provider a 60 day | ||||||
25 | written notice of each claim for which recovery is sought | ||||||
26 | and the reasons for the recovery using a standard code from |
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1 | the list established under paragraph (5) of subsection (g). | ||||||
2 | Record requests in a post payment audit may not exceed the | ||||||
3 | standards set forth in the Medicare Fee for Service | ||||||
4 | Recovery Audit Program for the provider type being audited, | ||||||
5 | adjusted for the provider's Medicaid volumes. Post-payment | ||||||
6 | recovery based on lack of medical necessity for claims that | ||||||
7 | were previously approved based on a medical necessity | ||||||
8 | review can only occur if it is demonstrated by the MCO that | ||||||
9 | the information provided at the time of the previous review | ||||||
10 | was knowingly materially inaccurate or incomplete at the | ||||||
11 | time the information was provided by the provider. | ||||||
12 | (7) If an MCO denies payment of or reduces the rate of | ||||||
13 | payment of a claim for a service which was: | ||||||
14 | (A) provided in good faith following the receipt of | ||||||
15 | a service authorization by the MCO and the denial is | ||||||
16 | for lack of service authorization, the MCO shall be | ||||||
17 | required to pay the provider double the amount due the | ||||||
18 | provider as a penalty add-on, in addition to the | ||||||
19 | standard contractual rate of reimbursement, or as | ||||||
20 | required by law, that would have been due for the | ||||||
21 | service if no denial had occurred; or | ||||||
22 | (B) provided in good faith and denied for | ||||||
23 | insufficient documentation and subsequently determined | ||||||
24 | that the claim contained all information necessary to | ||||||
25 | process and approve payment of the claim, the MCO shall | ||||||
26 | be required to pay the provider a penalty add-on, in |
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1 | addition to the standard contractual rate of | ||||||
2 | reimbursement or as required by law, equal to the value | ||||||
3 | of the amount owed the provider pursuant to the | ||||||
4 | standard contractual rate of reimbursement or as | ||||||
5 | required by law. Such penalty add-on shall be due and | ||||||
6 | payable to the provider within 30 days of payment of | ||||||
7 | the original claim payment. | ||||||
8 | The penalties imposed under this paragraph shall be due | ||||||
9 | in addition to any interest owed pursuant to the timely | ||||||
10 | payment provisions of subsection (g). | ||||||
11 | (h) The Department shall not expand mandatory MCO | ||||||
12 | enrollment into new counties beyond those counties already | ||||||
13 | designated by the Department as of June 1, 2014 for the | ||||||
14 | individuals whose eligibility for medical assistance is not the | ||||||
15 | seniors or people with disabilities population until the | ||||||
16 | Department provides an opportunity for accountable care | ||||||
17 | entities and MCOs to participate in such newly designated | ||||||
18 | counties. | ||||||
19 | (i) The requirements of this Section apply to contracts | ||||||
20 | with accountable care entities and MCOs entered into, amended, | ||||||
21 | or renewed after June 16, 2014 (the effective date of Public | ||||||
22 | Act 98-651).
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23 | (j) The requirements of this Section added by this | ||||||
24 | amendatory Act of the 101st General Assembly shall apply to | ||||||
25 | services provided on or after the first day of the month that | ||||||
26 | begins 60 days after the effective date of this amendatory Act |
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1 | of the 101st General Assembly. | ||||||
2 | (Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16; | ||||||
3 | 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff. | ||||||
4 | 6-4-18.) | ||||||
5 | (305 ILCS 5/5-30.11 new) | ||||||
6 | Sec. 5-30.11. Discharge notification and facility | ||||||
7 | placement of individuals; managed care. Whenever a hospital | ||||||
8 | provides notice to a managed care organization (MCO) that an | ||||||
9 | individual covered under the State's medical assistance | ||||||
10 | program has received a discharge order from the attending | ||||||
11 | physician and is ready for discharge from an inpatient hospital | ||||||
12 | stay to another level of care, the MCO shall secure the | ||||||
13 | individual's placement in or transfer to another facility | ||||||
14 | within 24 hours of receiving the hospital's notification, or | ||||||
15 | shall pay the hospital a daily rate equal to the hospital's | ||||||
16 | daily rate associated with the stay ending, including all | ||||||
17 | applicable add-on adjustment payments.
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18 | Section 99. Effective date. This Act takes effect upon | ||||||
19 | becoming law.
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