To: All Medical Assistance Program Providers
Re: Reminder Second Notice: New HFS Provider Resolution Process and Portal effective 02/28/2020
This notice is second in a series of notices regarding the implementation of the new provider MCO resolution portal. Effective 02/28/2020, all providers will now submit unresolved issues with an MCO via the new secure web-based Provider Resolution portal. The link to the Resolution Portal is found on HFS’ Care Coordination Webpage, or may be accessed directly from the HFS Managed Care Provider Resolution Webpage. Beginning 02/28/2020, HFS will suspend/stop receiving complaints in the current portal. For existing open tickets, HFS will work to resolve them with the providers and MCOs expeditiously under the current process. Tickets that are submitted in the new portal on or after 02/28/2020 will be processed under the new resolution process and applicable timeframes 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.
Requirement Reminders for Submitting Provider Disputes
As provided under the new provider resolution process, providers must first work with the MCOs regarding any issues or complaints. All issues must be submitted to the MCOs internal dispute process before submitting a ticket in the portal. Providers are responsible for working with MCOs to understand their internal MCO dispute process. If it is determined that a complaint was submitted in the portal, 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.
A list of the new Provider Portal Resolution Requirements can be found in the first Provider Portal Notice issued February 21, 2020. As outlined in the new requirements, providers must use the new standard Complaints/Claims-Issue template which can be found here when submitting two (2) or more similar complaints with the same MCO. Additionally, the MCOs are required to assign the provider a tracking number for each dispute submitted.
Below are the timelines for submitting complaints in the new Resolution Portal:
1. Complaint Submission Process: Disputes that have already been submitted to the MCO internal dispute resolution process may be submitted to the new Resolution Portal no sooner than thirty (30) calendar days after submitting to the MCO's internal process and no later than sixty (60) calendar days after submitting the dispute to the MCO’s internal process. As stated above, if it is determined that a complaint ticket was submitted outside of these timeframes, the complaint ticket will be immediately closed. NOTE: The MCO 30 calendar day resolution period begins the day that the MCO receives the dispute from the provider and the tracking number is assigned.
a. The provider’s submission to the portal must include the date the disputed complaint(s) was filed with the MCO’s internal provider dispute resolution process and the corresponding MCO provided tracking number. For submission of 2 or more same or similar complaints via the Complaints/Claims-Issue template, the tracking number should be assigned to the template (not individual complaint).
b. The Portal staff shall present complaints to the appropriate MCO within 10 business days of receipt via the Resolution Portal.
2. MCO Written Response/Proposal: The MCOs shall then have thirty 30 calendar days to issue its written proposal to resolve the disputed complaint ticket. Sanctions will apply to MCOs if a response is not submitted within 30 days.
a. If the MCO requires additional information from the provider, the MCO must request the additional information from the provider within five (5) business days of receiving the complaint ticket from the provider resolution portal.
b. When additional information is requested from the provider by the MCO within the timeframes described above, the provider has five (5) business days to provide the additional information or demonstrate that it was already provided to the MCO.
c. During the resolution process, the MCO or the provider may request, through the provider complaint portal, HFS to authorize a single thirty (30) calendar day extension for either the MCO or Provider, but not both. An extension request that occurs after the timelines discussed in subsections (1a) and (1b) must be made no later than seven (7) calendar days prior to the end of the initial thirty (30) calendar day period. Approval of the extension is at the discretion of HFS. Only one (1) extension is possible in extenuating circumstances to either the provider or the MCO, but not both (as approved by HFS). An approved extension adds thirty (30) calendar days to the initial thirty (30) calendar day period, for a total of sixty (60) calendar days within which the MCO must develop a written proposal to resolve the complaint ticket.
3. Provider Response: If the provider disagrees with the MCO's written proposal, the provider has thirty (30) calendar days to request HFS to review the dispute and make a final determination.
a. Within thirty (30) calendar days of a provider’s request for HFS review, both the MCO and the provider shall deliver all relevant information to HFS, including contact information for knowledgeable personnel.
4. HFS Decision: Within thirty (30) calendar days after the timeframe discussed in subsection (3a), HFS shall provide a written decision on the complaint ticket that reflects and is consistent with applicable contract terms, written HFS policies and procedures, and state and federal law and regulations. The decision of HFS is final. Disputes between MCOs and providers presented to HFS for resolution are not contested cases, and do not confer any right to an administrative hearing.
HFS will make available a WebEx recording that outlines the Provider dispute portal. The link to the WebEx recording will be included in the forthcoming Third Provider Portal Notice.
Please note that this new provider resolution 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.
Deputy Administrator, Care Coordination