Full Text of SB2949 99th General Assembly
SB2949 99TH GENERAL ASSEMBLY
99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
Introduced 2/18/2016, by Sen. David Koehler
SYNOPSIS AS INTRODUCED:
305 ILCS 5/5F-32
305 ILCS 5/5F-33 new
Amends the Illinois Public Aid Code. In a provision concerning
non-emergency prior approvals and appeals under the Medicare-Medicaid
Alignment Initiative Demonstration Project, requires Managed Care
Organizations (MCOs) to have a method of receiving prior approval requests
24 hours a day, 7 days a week, 365 days a year from (rather than for)
nursing home residents, physicians, or providers (rather than nursing home
residents). Provides that in a non-emergency situation, in the event a
resident's physician orders a service, treatment, or test that is not
approved by the MCO, the enrollee, physician, or provider may utilize an
expedited appeal to the MCO (rather than the physician and the provider may
utilize an expedited appeal to the MCO). Requires the MCO to notify all
individuals who file an expedited appeal of the MCO's decision within 24
hours after receipt of all required information. Adds provisions concerning
payment of claims submitted by a provider to a MCO, including: (i) the time
period within which a claim must be reviewed and paid; (ii) MCO
notification regarding the corrective action needed to permit payment of a
rejected or denied claim; (iii) MCO notification on coding and
documentation requirements; and (iv) the establishment of a claims
mediation process to mediate rejected or denied claims.
|FISCAL NOTE ACT MAY APPLY|
A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
The Illinois Public Aid Code is amended by
changing Section 5F-32 and by adding Section 5F-33 as follows:
(305 ILCS 5/5F-32)
Non-emergency prior approval and appeal.
(a) MCOs must have a method of receiving prior approval
requests 24 hours a day, 7 days a week, 365 days a year
nursing home residents
, physicians, or providers
. If a response
is not provided within 24 hours of the request and the nursing
home is required by regulation to provide a service because a
physician ordered it, the MCO must pay for the service if it is
a covered service under the MCO's contract in the Demonstration
Project, provided that the request is consistent with the
policies and procedures of the MCO.
In a non-emergency situation, notwithstanding any
provisions in State law to the contrary, in the event a
resident's physician orders a service, treatment, or test that
is not approved by the MCO, the
provider may utilize an expedited appeal to the MCO.
If an enrollee
or provider requests an
expedited appeal pursuant to 42 CFR 438.410, the MCO shall
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individual filing the appeal, whether it is the
within 24 hours after the
submission of the appeal of all information from the enrollee
or provider that the MCO requires to evaluate the
appeal. The MCO shall
notify the individual filing the appeal
of the MCO's
decision on an expedited appeal within 24
hours after receipt of the required information.
(b) While the appeal is pending or if the ordered service,
treatment, or test is denied after appeal, the Department of
Public Health may not cite the nursing home for failure to
provide the ordered service, treatment, or test. The nursing
home shall not be liable or responsible for an injury in any
regulatory proceeding for the following:
(1) failure to follow the appealed or denied order; or
(2) injury to the extent it was caused by the delay or
failure to perform the appealed or denied service,
treatment, or test.
Provided however, a nursing home shall continue to monitor,
document, and ensure the patient's safety. Nothing in this
subsection (b) is intended to otherwise change the nursing
home's existing obligations under State and federal law to
appropriately care for its residents.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-33 new)
Payment of claims.
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(a) Claims submitted by a provider to a MCO in the form and
manner requested by the MCO shall be reviewed and paid within
30 days of receipt.
(b) A claim that is rejected or denied shall be accompanied
with a detailed description of the corrective action needed to
permit payment of the claim. A claim resubmitted in compliance
with the corrective action requested shall be paid immediately.
(c) A MCO that rejects or denies a claim a second time
shall notify the provider by phone and shall provide assistance
to the provider to correct any deficiencies in the claim that
are preventing payment.
(d) The form and manner required by each individual MCO for
payment of claims along with all necessary coding and
documentation requirements shall be provided in writing to each
provider within 5 days of the provider entering into a contract
with a MCO. Providers under contract with a MCO on the
effective date of this amendatory Act of the 99th General
Assembly shall be provided with a written copy of these
requirements within 30 days. Any changes to these requirements
shall be delivered in writing to all providers under contract
with the MCO 30 days prior to the effective date of the change.
(e)(1) Within 90 days of the effective date of this
amendatory Act of the 99th General Assembly, the Department
shall enter into a contract with an independent body to mediate
rejected or denied claims.
(2) The cost of the mediation service shall be underwritten
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by an annual fee collected from each MCO under contract with
the Department for either the Integrated Care Program or the
Demonstration Project and shall be available to providers
participating in the Integrated Care Program and Demonstration
Project. The amount of the fee shall be set by rule and shall
not generate an amount in excess of the cost of providing the
(3) The claims mediation process established pursuant to
this subsection shall be available to any provider whose claim
submitted pursuant to subsections (a) and (b) is rejected or
(4) The Department shall publish on its website guidelines
and an application form for initiating mediation.
(5) The Department shall adopt any rules necessary to
implement this Section.