Provider Notice Issued 02/21/2020

Date:    February 21, 2020
 
To:       All Medical Assistance Program Providers
 
Re:      First Notice: New HFS Provider Resolution Process and Portal Effective 02/28/2020. 
 
 
The Department of Healthcare and Family Services (HFS) continues to recognize the importance of providers having a mechanism for reporting and resolving issues encountered with an individual Medicaid MCO when these issues cannot be resolved using existing processes designated by the MCO. Effective February 28, 2020, HFS will implement a new dispute resolution process for submitting, monitoring, and resolving disputes between a provider and an MCO, as required by Public Act 101-0209 (SB1321). Proposed amendments to 89 Ill. Adm. Code Section 140 are currently in process.
 
Effective February 28, 2020, all providers will be required to submit unresolved disputes with an MCO to HFS via the new secure web-based Provider Resolution portal. The link to the new Provider Complaint Resolution Portal may be found on HFS’ Care Coordination webpage or accessed directly from the HFS Managed Care Provider Resolution Webpage. Beginning February 28, 2020, HFS will suspend/stop receiving complaints in the current portal. For existing open tickets, HFS will work with the providers and MCOs to resolve them expeditiously under the current process. Tickets that are submitted in the new portal on or after February 28, 2020, will be processed under the new provider dispute resolution process and applicable timeframes.
 
Requirements for Submitting Provider Disputes
The new provider dispute resolution process requires providers to first use the MCO internal dispute process before submitting a complaint to HFS.   Disputes submitted to the MCO internal dispute resolution process may be submitted to the new HFS Complaint Resolution Portal: 1) no sooner than 30 days after submitting to the MCO's internal process and 2.) no later than 60 days after submitting to the MCO’s internal process. If HFS determines a complaint was submitted sooner than 30 days or later than 60 days after submitting the dispute to the MCO’s internal process, the complaint will be immediately closed.
 
HFS staff will follow Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy procedures when using the secured HFS Managed Care Provider Resolution site. Providers and MCOs are expected to also follow HIPAA procedures to secure the data being shared via the portal.

What is new?
  • In the new portal, all providers or designated billing staff/agents will be required to set up an account to register with the portal in order to access and submit disputes. Registration will be available through the HFS Managed Care Provider Resolution Webpage.
  • All MCOs are required to assign the provider a tracking number for each complaint submitted through the MCO internal dispute process. The provider must then enter this MCO-assigned tracking number in the HFS Provider Resolution portal when completing the complaint ticket. 
  • Providers must use the new standard Complaints/Claims-Issue template when submitting two (2) or more of the same or similar complaints with the same MCO. Providers are limited to a maximum of 100 similar complaints/claims on a template.
  • When submitting a template, providers should not mix complaints/claims from different MCOs or different providers/facilities. Separate complaints/claims should be filed, with separate templates for each unique provider/facility (by Medicaid Tax ID and location address).
  • When an MCO requests additional information from a provider, the provider must provide the additional information or demonstrate that this information was already provided to the MCO. Incomplete complaints or lack of response by the provider will cause the complaint to be closed in the portal. 
  • MCOs must respond to the provider with a plan to address the complaint; the plan must include a time period in which the complaint will be investigated, and an answer given.
  • Only one (1) 30-day extension is possible in extenuating circumstances to either the provider or the MCO, but not both (as approved by HFS).
  • If complaints cannot be resolved, HFS will make a final decision.  The HFS decision on all disputes shall be final.
 
HFS will provide additional guidance in a second Provider Notice to reinforce the timeframes for actions in the process, broken down by business or calendar day, responsible party/decision maker and expected actions by providers, MCOs and HFS.
 
Please note that this new portal is designed specifically for issues enrolled providers have with Illinois Medicaid MCOs under the managed care programs. Provider complaints regarding the resolution of Medicaid fee-for-service issues should continue to be directed to HFS at 877-782-5565.
 
Questions regarding this notice may be directed to the Department’s Bureau of Managed Care at
217-524-7478.
 
 
Robert Mendonsa
Deputy Administrator, Care Coordination
 
 

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