Illinois General Assembly - Full Text of HB6123
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Full Text of HB6123  99th General Assembly


Sen. David Koehler

Filed: 5/20/2016





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2    AMENDMENT NO. ______. Amend House Bill 6123, AS AMENDED, by
3replacing everything after the enacting clause with the
5    "Section 5. The Illinois Public Aid Code is amended by
6changing Sections 5F-10 and 5F-32 and by adding Sections 5-30.3
7and 5F-33 as follows:
8    (305 ILCS 5/5-30.3 new)
9    Sec. 5-30.3. Provider inquiry portal. The Department shall
10establish, no later than January 1, 2018, a web-based portal to
11accept inquiries and requests for assistance from managed care
12organizations under contract with the State and providers under
13contract with managed care organizations to provide direct
15    (305 ILCS 5/5F-10)



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1    Sec. 5F-10. Scope. This Article applies to policies and
2contracts amended, delivered, issued, or renewed on or after
3the effective date of this amendatory Act of the 98th General
4Assembly for the nursing home component of the
5Medicare-Medicaid Alignment Initiative and the Managed
6Long-Term Services and Support Program. This Article does not
7diminish a managed care organization's duties and
8responsibilities under other federal or State laws or rules
9adopted under those laws and the 3-way Medicare-Medicaid
10Alignment Initiative contract and the Managed Long-Term
11Services 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
16requests 24 hours a day, 7 days a week, 365 days a year from for
17nursing home residents, physicians, or providers. If a response
18is not provided within 24 hours of the request and the nursing
19home is required by regulation to provide a service because a
20physician ordered it, the MCO must pay for the service if it is
21a covered service under the MCO's contract in the Demonstration
22Project, provided that the request is consistent with the
23policies and procedures of the MCO.
24    In a non-emergency situation, notwithstanding any
25provisions in State law to the contrary, in the event a



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1resident's physician orders a service, treatment, or test that
2is not approved by the MCO, the enrollee, physician, or and the
3provider may utilize an expedited appeal to the MCO.
4    If an enrollee, physician, or provider requests an
5expedited appeal pursuant to 42 CFR 438.410, the MCO shall
6notify the individual filing the appeal, whether it is the
7enrollee, physician, or provider, within 24 hours after the
8submission of the appeal of all information from the enrollee,
9physician, or provider that the MCO requires to evaluate the
10appeal. The MCO shall notify the individual filing the appeal
11of the MCO's render a decision on an expedited appeal within 24
12hours after receipt of the required information.
13    (b) While the appeal is pending or if the ordered service,
14treatment, or test is denied after appeal, the Department of
15Public Health may not cite the nursing home for failure to
16provide the ordered service, treatment, or test. The nursing
17home shall not be liable or responsible for an injury in any
18regulatory 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.
23Provided however, a nursing home shall continue to monitor,
24document, and ensure the patient's safety. Nothing in this
25subsection (b) is intended to otherwise change the nursing
26home's existing obligations under State and federal law to



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1appropriately 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
6by a provider to a managed care organization in the form and
7manner requested by the managed care organization shall be
8reviewed and paid within 30 days of receipt.
9    (b) A managed care organization must provide a status
10update within 60 days of the submission of a claim.
11    (c) A claim that is rejected or denied shall clearly state
12the reason for the rejection or denial in sufficient detail to
13permit the provider to understand the justification for the
15    (d) The Department shall work with stakeholders,
16including, but not limited to, managed care organizations and
17nursing home providers, to train them on the application of
18standardized codes for long-term care services.
19    (e) Managed care organizations shall provide a manual
20clearly explaining billing and claims payment procedures,
21including points of contact for provider services centers,
22within 15 days of a provider entering into a contract with a
23managed care organization. The manual shall include all
24necessary coding and documentation requirements. Providers
25under contract with a managed care organization on the



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1effective date of this amendatory Act of the 99th General
2Assembly shall be provided with an electronic copy of these
3requirements within 30 days of the effective date of this
4amendatory Act of the 99th General Assembly. Any changes to
5these requirements shall be delivered electronically to all
6providers under contract with the managed care organization 30
7days prior to the effective date of the change.".