Sen. David Koehler
Filed: 5/20/2016
| |||||||
| |||||||
| |||||||
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) |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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. ".
|