Full Text of HB6123 99th General Assembly
HB6123sam002 99TH GENERAL ASSEMBLY | Sen. David Koehler Filed: 5/20/2016
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| 1 | | AMENDMENT TO HOUSE BILL 6123
| 2 | | AMENDMENT NO. ______. Amend House Bill 6123, AS AMENDED, by | 3 | | replacing everything after the enacting clause with the | 4 | | following:
| 5 | | "Section 5. The Illinois Public Aid Code is amended by | 6 | | changing Sections 5F-10 and 5F-32 and by adding Sections 5-30.3 | 7 | | and 5F-33 as follows: | 8 | | (305 ILCS 5/5-30.3 new) | 9 | | Sec. 5-30.3. Provider inquiry portal. The Department shall | 10 | | establish, no later than January 1, 2018, a web-based portal to | 11 | | accept inquiries and requests for assistance from managed care | 12 | | organizations under contract with the State and providers under | 13 | | contract with managed care organizations to provide direct | 14 | | care. | 15 | | (305 ILCS 5/5F-10) |
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| 1 | | Sec. 5F-10. Scope. This Article applies to policies and | 2 | | contracts amended, delivered, issued, or renewed on or after | 3 | | the effective date of this amendatory Act of the 98th General | 4 | | Assembly for the nursing home component of the | 5 | | Medicare-Medicaid Alignment Initiative and the Managed | 6 | | Long-Term Services and Support Program . This Article does not | 7 | | diminish a managed care organization's duties and | 8 | | responsibilities under other federal or State laws or rules | 9 | | adopted under those laws and the 3-way Medicare-Medicaid | 10 | | Alignment Initiative contract and the Managed Long-Term | 11 | | Services and Support Program contract .
| 12 | | (Source: P.A. 98-651, eff. 6-16-14.) | 13 | | (305 ILCS 5/5F-32) | 14 | | Sec. 5F-32. Non-emergency prior approval and appeal. | 15 | | (a) MCOs must have a method of receiving prior approval | 16 | | requests 24 hours a day, 7 days a week, 365 days a year from for | 17 | | nursing home residents , physicians, or providers . If a response | 18 | | is not provided within 24 hours of the request and the nursing | 19 | | home is required by regulation to provide a service because a | 20 | | physician ordered it, the MCO must pay for the service if it is | 21 | | a covered service under the MCO's contract in the Demonstration | 22 | | Project, provided that the request is consistent with the | 23 | | policies and procedures of the MCO. | 24 | | In a non-emergency situation, notwithstanding any | 25 | | provisions in State law to the contrary, in the event a |
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| 1 | | resident's physician orders a service, treatment, or test that | 2 | | is not approved by the MCO, the enrollee, physician , or and the | 3 | | provider may utilize an expedited appeal to the MCO. | 4 | | If an enrollee , physician, or provider requests an | 5 | | expedited appeal pursuant to 42 CFR 438.410, the MCO shall | 6 | | notify the individual filing the appeal, whether it is the | 7 | | enrollee , physician, or provider , within 24 hours after the | 8 | | submission of the appeal of all information from the enrollee , | 9 | | physician, or provider that the MCO requires to evaluate the | 10 | | appeal. The MCO shall notify the individual filing the appeal | 11 | | of the MCO's render a decision on an expedited appeal within 24 | 12 | | hours after receipt of the required information. | 13 | | (b) While the appeal is pending or if the ordered service, | 14 | | treatment, or test is denied after appeal, the Department of | 15 | | Public Health may not cite the nursing home for failure to | 16 | | provide the ordered service, treatment, or test. The nursing | 17 | | home shall not be liable or responsible for an injury in any | 18 | | regulatory proceeding for the following: | 19 | | (1) failure to follow the appealed or denied order; or | 20 | | (2) injury to the extent it was caused by the delay or | 21 | | failure to perform the appealed or denied service, | 22 | | treatment, or test. | 23 | | Provided however, a nursing home shall continue to monitor, | 24 | | document, and ensure the patient's safety. Nothing in this | 25 | | subsection (b) is intended to otherwise change the nursing | 26 | | home's existing obligations under State and federal law to |
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| 1 | | appropriately care for its residents.
| 2 | | (Source: P.A. 98-651, eff. 6-16-14.) | 3 | | (305 ILCS 5/5F-33 new) | 4 | | Sec. 5F-33. Payment of claims. | 5 | | (a) Clean claims, as defined by the Department, submitted | 6 | | by a provider to a managed care organization in the form and | 7 | | manner requested by the managed care organization shall be | 8 | | reviewed and paid within 30 days of receipt. | 9 | | (b) A managed care organization must provide a status | 10 | | update within 60 days of the submission of a claim. | 11 | | (c) A claim that is rejected or denied shall clearly state | 12 | | the reason for the rejection or denial in sufficient detail to | 13 | | permit the provider to understand the justification for the | 14 | | action. | 15 | | (d) The Department shall work with stakeholders, | 16 | | including, but not limited to, managed care organizations and | 17 | | nursing home providers, to train them on the application of | 18 | | standardized codes for long-term care services. | 19 | | (e) Managed care organizations shall provide a manual | 20 | | clearly explaining billing and claims payment procedures, | 21 | | including points of contact for provider services centers, | 22 | | within 15 days of a provider entering into a contract with a | 23 | | managed care organization. The manual shall include all | 24 | | necessary coding and documentation requirements. Providers | 25 | | under contract with a managed care organization on the |
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| 1 | | effective date of this amendatory Act of the 99th General | 2 | | Assembly shall be provided with an electronic copy of these | 3 | | requirements within 30 days of the effective date of this | 4 | | amendatory Act of the 99th General Assembly. Any changes to | 5 | | these requirements shall be delivered electronically to all | 6 | | providers under contract with the managed care organization 30 | 7 | | days prior to the effective date of the change. ".
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