|Public Act 099-0719|
|HB6123 Enrolled||LRB099 19687 MJP 44084 b|
AN ACT concerning State government.
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 Sections 5F-10 and 5F-32 and by adding Sections 5-30.3
and 5F-33 as follows:
(305 ILCS 5/5-30.3 new)
Provider inquiry portal.
The Department shall
establish, no later than January 1, 2018, a web-based portal to
accept inquiries and requests for assistance from managed care
organizations under contract with the State and providers under
contract with managed care organizations to provide direct
(305 ILCS 5/5F-10)
This Article applies to policies and
contracts amended, delivered, issued, or renewed on or after
the effective date of this amendatory Act of the 98th General
Assembly for the nursing home component of the
Medicare-Medicaid Alignment Initiative
and the Managed
Long-Term Services and Support Program
. This Article does not
diminish a managed care organization's duties and
responsibilities under other federal or State laws or rules
adopted under those laws and the 3-way Medicare-Medicaid
Alignment Initiative contract
and the Managed Long-Term
Services and Support Program contract
(Source: P.A. 98-651, eff. 6-16-14.)
(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
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.
(a) Clean claims, as defined by the Department, submitted
by a provider to a managed care organization in the form and
manner requested by the managed care organization shall be
reviewed and paid within 30 days of receipt.
(b) A managed care organization must provide a status
update within 60 days of the submission of a claim.
(c) A claim that is rejected or denied shall clearly state
the reason for the rejection or denial in sufficient detail to
permit the provider to understand the justification for the
(d) The Department shall work with stakeholders,
including, but not limited to, managed care organizations and
nursing home providers, to train them on the application of
standardized codes for long-term care services.
(e) Managed care organizations shall provide a manual
clearly explaining billing and claims payment procedures,
including points of contact for provider services centers,
within 15 days of a provider entering into a contract with a
managed care organization. The manual shall include all
necessary coding and documentation requirements. Providers
under contract with a managed care organization on the
effective date of this amendatory Act of the 99th General
Assembly shall be provided with an electronic copy of these
requirements within 30 days of the effective date of this
amendatory Act of the 99th General Assembly. Any changes to
these requirements shall be delivered electronically to all
providers under contract with the managed care organization 30
days prior to the effective date of the change.