Date: January 10, 2020
To: Participating Hospitals: Chief Executive Officers, Chief Financial Officers, Patient Accounts Managers, and Health Information Management Directors
Re: New Utilization Review Process for Medical Assistance No Grant (MANG) Pended Patients
The Illinois Department of Healthcare and Family Services (HFS), in conjunction with its Quality Improvement Organization, eQHealth Solutions (eQHealth), has created a new process to allow hospitals to submit inpatient concurrent review requests for MANG Pended patients. The requests are only for patients who have applied for Medicaid, but the application is categorized as “Medical Assistance No Grant” and is in pending status. This new MANG Pended review does not apply to child and adolescent psychiatric admissions, or prior authorizations for coronary artery bypass grafts or back surgery.
eQHealth has created a feature in eQSuite® that will permit providers to submit an inpatient admission review request for MANG Pended patients. This feature will create a temporary identification number with the initials TN followed by a series of numbers. This TN number will enable hospitals to submit an admission review request in eQSuite® for those with MANG Pended status.
Utilization review requirements for MANG Pended requests are the same as for patients who already have a Medicaid recipient identification number (RIN). eQHealth’s medical necessity review process is also the same. Although eQHealth will create a Treatment Authorization Number (TAN), the TAN will not be activated for billing purposes until the patient’s Medicaid application has been approved and a RIN has been issued.
When the Medicaid application is approved, and a RIN assigned, it is the hospital’s responsibility to access a utility in eQSuite® to locate the review using the TAN number. The hospital then can enter the RIN. The previously generated TAN will now be activated and transmitted to HFS.
· For DRG inpatient reviews, providers will follow the same discharge review process. Once this has occurred, the provider can prepare and submit their claim to HFS.
· If the inpatient review is from a Per Diem provider, a continued stay request is required.
If a patient requires a continued stay review and their Medicaid application is still pending, the hospital will call in the continued stay request to eQHealth’s Certification line at 800-418-4033. An eQHealth Utilization Review Coordinator (URC) will manually record the patient’s information and then perform a medical necessity review. Once the patient’s Medicaid application is approved and a RIN has been assigned, the provider will be able to enter into eQSuite the previously approved continued stay reviews using the inpatient admission TAN.
If a patient’s Medicaid application is not approved, the TAN generated by eQHealth for any inpatient admission or continued stays will become void. The provider will not be able to bill HFS for services rendered to the patient whose Medicaid application was not approved.
eQHealth will conduct Provider Training on this new utilization review process for MANG Pended patients. Hospitals will receive a Provider Update from eQHealth with dates and times of the scheduled trainings. While the new system will be made available for provider use on Monday, January 13th, providers are strongly encouraged to participate in the Provider Trainings prior to utilizing the new process.
All billing questions for approved MANG Pended patients should be directed to the Bureau of Hospital and Provider Services at 877-782-5565.