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| Public Act 099-0719 | ||||
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AN ACT concerning State government.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. 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) | ||||
Sec. 5-30.3. 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 | ||||
care. | ||||
(305 ILCS 5/5F-10) | ||||
Sec. 5F-10. Scope. 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.
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(Source: P.A. 98-651, eff. 6-16-14.) | ||
(305 ILCS 5/5F-32) | ||
Sec. 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 from for | ||
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 enrollee, physician, or and the | ||
provider may utilize an expedited appeal to the MCO. | ||
If an enrollee, physician, or provider requests an | ||
expedited appeal pursuant to 42 CFR 438.410, the MCO shall | ||
notify the individual filing the appeal, whether it is the | ||
enrollee, physician, or provider, within 24 hours after the | ||
submission of the appeal of all information from the enrollee, | ||
physician, or provider that the MCO requires to evaluate the | ||
appeal. The MCO shall notify the individual filing the appeal | ||
of the MCO's render a 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.
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(Source: P.A. 98-651, eff. 6-16-14.) | ||
(305 ILCS 5/5F-33 new) | ||
Sec. 5F-33. 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 | ||
action. | ||
(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.
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