Illinois General Assembly - Full Text of SB2949
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Full Text of SB2949  99th General Assembly




State of Illinois
2015 and 2016


Introduced 2/18/2016, by Sen. David Koehler


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.

LRB099 20643 KTG 45238 b






SB2949LRB099 20643 KTG 45238 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5F-32 and by adding Section 5F-33 as follows:
6    (305 ILCS 5/5F-32)
7    Sec. 5F-32. Non-emergency prior approval and appeal.
8    (a) MCOs must have a method of receiving prior approval
9requests 24 hours a day, 7 days a week, 365 days a year from for
10nursing home residents, physicians, or providers. If a response
11is not provided within 24 hours of the request and the nursing
12home is required by regulation to provide a service because a
13physician ordered it, the MCO must pay for the service if it is
14a covered service under the MCO's contract in the Demonstration
15Project, provided that the request is consistent with the
16policies and procedures of the MCO.
17    In a non-emergency situation, notwithstanding any
18provisions in State law to the contrary, in the event a
19resident's physician orders a service, treatment, or test that
20is not approved by the MCO, the enrollee, physician, or and the
21provider may utilize an expedited appeal to the MCO.
22    If an enrollee, physician, or provider requests an
23expedited appeal pursuant to 42 CFR 438.410, the MCO shall



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1notify the individual filing the appeal, whether it is the
2enrollee, physician, or provider, within 24 hours after the
3submission of the appeal of all information from the enrollee,
4physician, or provider that the MCO requires to evaluate the
5appeal. The MCO shall notify the individual filing the appeal
6of the MCO's render a decision on an expedited appeal within 24
7hours after receipt of the required information.
8    (b) While the appeal is pending or if the ordered service,
9treatment, or test is denied after appeal, the Department of
10Public Health may not cite the nursing home for failure to
11provide the ordered service, treatment, or test. The nursing
12home shall not be liable or responsible for an injury in any
13regulatory proceeding for the following:
14        (1) failure to follow the appealed or denied order; or
15        (2) injury to the extent it was caused by the delay or
16    failure to perform the appealed or denied service,
17    treatment, or test.
18Provided however, a nursing home shall continue to monitor,
19document, and ensure the patient's safety. Nothing in this
20subsection (b) is intended to otherwise change the nursing
21home's existing obligations under State and federal law to
22appropriately care for its residents.
23(Source: P.A. 98-651, eff. 6-16-14.)
24    (305 ILCS 5/5F-33 new)
25    Sec. 5F-33. Payment of claims.



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1    (a) Claims submitted by a provider to a MCO in the form and
2manner requested by the MCO shall be reviewed and paid within
330 days of receipt.
4    (b) A claim that is rejected or denied shall be accompanied
5with a detailed description of the corrective action needed to
6permit payment of the claim. A claim resubmitted in compliance
7with the corrective action requested shall be paid immediately.
8    (c) A MCO that rejects or denies a claim a second time
9shall notify the provider by phone and shall provide assistance
10to the provider to correct any deficiencies in the claim that
11are preventing payment.
12    (d) The form and manner required by each individual MCO for
13payment of claims along with all necessary coding and
14documentation requirements shall be provided in writing to each
15provider within 5 days of the provider entering into a contract
16with a MCO. Providers under contract with a MCO on the
17effective date of this amendatory Act of the 99th General
18Assembly shall be provided with a written copy of these
19requirements within 30 days. Any changes to these requirements
20shall be delivered in writing to all providers under contract
21with the MCO 30 days prior to the effective date of the change.
22    (e)(1) Within 90 days of the effective date of this
23amendatory Act of the 99th General Assembly, the Department
24shall enter into a contract with an independent body to mediate
25rejected or denied claims.
26    (2) The cost of the mediation service shall be underwritten



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1by an annual fee collected from each MCO under contract with
2the Department for either the Integrated Care Program or the
3Demonstration Project and shall be available to providers
4participating in the Integrated Care Program and Demonstration
5Project. The amount of the fee shall be set by rule and shall
6not generate an amount in excess of the cost of providing the
8    (3) The claims mediation process established pursuant to
9this subsection shall be available to any provider whose claim
10submitted pursuant to subsections (a) and (b) is rejected or
12    (4) The Department shall publish on its website guidelines
13and an application form for initiating mediation.
14    (5) The Department shall adopt any rules necessary to
15implement this Section.