To: All Medical Assistance Program Providers
Re: HFS Managed Care Provider Resolution Portal Updates
This notice shares updates and reminders
with providers about the HFS Managed Care Provider Resolution Portal.
Illinois Department of Healthcare and Family Service’s (Department) Managed
Care Provider Resolution Portal is used specifically for issues providers have
with Illinois Medicaid Managed Care Organizations (MCOs) participating in the
Managed Care programs. Provider complaints regarding the resolution of
Medicaid fee-for-service issues should continue to be directed to the
Department at 877-782-5565.
· All providers are required to submit unresolved disputes with an MCO
via the secure Provider Resolution Portal. Providers can access the portal,
and view tutorials at:
· The Managed Care Provider Resolution Portal handles complaints
relative to the Medicaid portion only, not Medicare. This also
includes denials for a Medicare-covered service for a dually eligible
client. Medicare only complaints submitted in the portal will be closed.
In working with the MCO on Medicare issues, providers should refer to the
Centers for Medicare and Medicaid Services (CMS) Medicare website for billing
information, fee schedules, and appeals and grievances guidelines:
Providers or designated billing
staff must first register with the portal before a complaint can be submitted.
Portal registration materials and instructions for individual and multiple
facility sites are available on the portal home page.
The Department requires that providers first use the MCO internal
dispute/appeals process to attempt to resolve a complaint. This means providers
must follow and exhaust all processes provided by MCOs to resolve a
dispute, including peer-to-peer disputes, before submitting a complaint through
the portal. Communication
between the provider and the MCO during the initial dispute resolution period
is encouraged. Disputes submitted to the MCO internal dispute
resolution process may be submitted to the portal:
No sooner than
30 calendar days after submitting to the MCO's internal process; and,
No later than
60 calendar days after submitting to the MCO’s internal process.
Providers must follow the 30/60 calendar
portal ticket submission timeframes. Tickets that do not follow the 30/60
calendar day timeframes will be closed.
MCOs are required to assign the provider a tracking number for each complaint
submitted through their internal dispute/appeals process. Providers must enter
this MCO assigned tracking number in the Provider Resolution Portal when
completing a complaint ticket. Complaints submitted without a tracking number
will be closed. Providers must contact the MCO to receive a tracking
More information about each MCOs dispute/appeals process and tracking
numbers is provided at this link:
· Any complaint that involves failure to obtain a prior
authorization where required will be closed. If the provider received
a prior authorization, that information must be provided to the MCO as part of
the MCO’s internal dispute process. Note: receipt of a prior
authorization does not guarantee payment.
· The Department strongly encourages providers to review the Comprehensive
Billing Manual developed by the Illinois Association of Medicaid Health Plans
(IAMHP). The Department has approved these guidelines for posting, and they include MCO
contacts, clearinghouse information, and more.
MCO can request additional information from a provider within five business days
of receiving the ticket in the portal. The provider must provide (submit)
the additional information requested in the portal within 5 business days or
demonstrate that this information was previously shared with the MCO. If the provider does not respond within the 5 business
days, the ticket will be closed. Providers are encouraged to read and respond
to portal email notifications timely.
that do not follow the portal guidelines, including incomplete submissions, will
Questions regarding the portal, or
provider portal registration, can be submitted to the Bureau of Managed Care
and Portal team at HFS.PortalInquiries@Illinois.gov
Deputy Administrator, Care