HB6123 EnrolledLRB099 19687 MJP 44084 b

1    AN ACT concerning State government.
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 Sections 5F-10 and 5F-32 and by adding Sections 5-30.3
6and 5F-33 as follows:
7    (305 ILCS 5/5-30.3 new)
8    Sec. 5-30.3. Provider inquiry portal. The Department shall
9establish, no later than January 1, 2018, a web-based portal to
10accept inquiries and requests for assistance from managed care
11organizations under contract with the State and providers under
12contract with managed care organizations to provide direct
14    (305 ILCS 5/5F-10)
15    Sec. 5F-10. Scope. This Article applies to policies and
16contracts amended, delivered, issued, or renewed on or after
17the effective date of this amendatory Act of the 98th General
18Assembly for the nursing home component of the
19Medicare-Medicaid Alignment Initiative and the Managed
20Long-Term Services and Support Program. This Article does not
21diminish a managed care organization's duties and
22responsibilities under other federal or State laws or rules



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1adopted under those laws and the 3-way Medicare-Medicaid
2Alignment Initiative contract and the Managed Long-Term
3Services and Support Program contract.
4(Source: P.A. 98-651, eff. 6-16-14.)
5    (305 ILCS 5/5F-32)
6    Sec. 5F-32. Non-emergency prior approval and appeal.
7    (a) MCOs must have a method of receiving prior approval
8requests 24 hours a day, 7 days a week, 365 days a year from for
9nursing home residents, physicians, or providers. If a response
10is not provided within 24 hours of the request and the nursing
11home is required by regulation to provide a service because a
12physician ordered it, the MCO must pay for the service if it is
13a covered service under the MCO's contract in the Demonstration
14Project, provided that the request is consistent with the
15policies and procedures of the MCO.
16    In a non-emergency situation, notwithstanding any
17provisions in State law to the contrary, in the event a
18resident's physician orders a service, treatment, or test that
19is not approved by the MCO, the enrollee, physician, or and the
20provider may utilize an expedited appeal to the MCO.
21    If an enrollee, physician, or provider requests an
22expedited appeal pursuant to 42 CFR 438.410, the MCO shall
23notify the individual filing the appeal, whether it is the
24enrollee, physician, or provider, within 24 hours after the
25submission of the appeal of all information from the enrollee,



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



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1reviewed and paid within 30 days of receipt.
2    (b) A managed care organization must provide a status
3update within 60 days of the submission of a claim.
4    (c) A claim that is rejected or denied shall clearly state
5the reason for the rejection or denial in sufficient detail to
6permit the provider to understand the justification for the
8    (d) The Department shall work with stakeholders,
9including, but not limited to, managed care organizations and
10nursing home providers, to train them on the application of
11standardized codes for long-term care services.
12    (e) Managed care organizations shall provide a manual
13clearly explaining billing and claims payment procedures,
14including points of contact for provider services centers,
15within 15 days of a provider entering into a contract with a
16managed care organization. The manual shall include all
17necessary coding and documentation requirements. Providers
18under contract with a managed care organization on the
19effective date of this amendatory Act of the 99th General
20Assembly shall be provided with an electronic copy of these
21requirements within 30 days of the effective date of this
22amendatory Act of the 99th General Assembly. Any changes to
23these requirements shall be delivered electronically to all
24providers under contract with the managed care organization 30
25days prior to the effective date of the change.