305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-30.12)

Sec. 5-30.12. Managed care claim rejection and denial management.

(a) In order to provide greater transparency to managed care organizations (MCOs) and providers, the Department shall explore the availability of and, if reasonably available, procure technology that, for all electronic claims, with the exception of direct data entry claims, meets the following needs:

(1) The technology shall allow the Department to fully analyze the root cause of claims denials in the Medicaid managed care programs operated by the Department and expedite solutions that reduce the number of denials to the extent possible.

(2) The technology shall create a single electronic pipeline through which all claims from all providers submitted for adjudication by the Department or a managed care organization under contract with the Department shall be directed by clearing houses and providers or other claims submitting entities not using clearing houses prior to forwarding to the Department or the appropriate managed care organization.

(3) The technology shall cause all HIPAA-compliant responses to submitted claims, including rejections, denials, and payments, returned to the submitting provider to pass through the established single pipeline.

(4) The technology shall give the Department the ability to create edits to be placed at the front end of the pipeline that will reject claims back to the submitting provider with an explanation of why the claim cannot be properly adjudicated by the payer.

(5) The technology shall allow the Department to customize the language used to explain why a claim is being rejected and how the claim can be corrected for adjudication.

(6) The technology shall send copies of all claims and claim responses that pass through the pipeline, regardless of the payer to whom they are directed, to the Department's Enterprise Data Warehouse.

(b) If the Department chooses to implement front end edits or customized responses to claims submissions, the MCOs and other stakeholders shall be consulted prior to implementation and providers shall be notified of edits at least 30 days prior to their effective date.

(c) Neither the technology nor MCO policy shall require providers to submit claims through a process other than the pipeline. MCOs may request supplemental information needed for adjudication which cannot be contained in the claim file to be submitted separately to the MCOs.

(d) The technology shall allow the Department to fully analyze and report on MCO claims processing and payment performance by provider type.

(Source: P.A. 101-209, eff. 8-5-19.)

(305 ILCS 5/5-30.13)

Sec. 5-30.13. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information:

(1) The administrative expenses paid to the Medicaid managed care health plan.

(2) The amount of money the Medicaid managed care health plan has spent with Business Enterprise Program certified businesses.

(3) The amount of money the Medicaid managed care health plan has spent with minority-owned and women-owned businesses that are certified by other agencies or private organizations.

(4) The amount of money the Medicaid managed care health plan has spent with not-for-profit community-based organizations serving predominantly minority communities, as defined by the Department.

(5) The proportion of minorities, people with disabilities, and women that make up the staff of the Medicaid managed care health plan.

(6) Recommendations for increasing expenditures with minority-owned and women-owned businesses.

(7) A list of the types of services to which the Medicaid managed care health plan is contemplating adding new vendors.

(8) The certifications the Medicaid managed care health plan accepts for minority-owned and women-owned businesses.

(9) The point of contact for potential vendors seeking to do business with the Medicaid managed care health plan.

The Department shall publish the reports on its website and shall maintain each report on its website for 5 years. In May of 2020 and every May thereafter, the Department shall hold 2 annual public workshops, one in Chicago and one in Springfield. The workshops shall include each Medicaid managed care health plan and shall be open to vendor communities to discuss the submitted plans and to seek to connect vendors with the Medicaid managed care health plans.

(Source: P.A. 101-209, eff. 8-5-19; 102-558, eff. 8-20-21.)

(305 ILCS 5/5-30.14)

Sec. 5-30.14. Medicaid managed care organizations; preferred drug lists.

(a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy, and community-based organizations, providers, and entities with expertise in drug formulary development.

(b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website. Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls.

(c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall:

(A) convene and meet no less than once per calendar quarter;

(B) provide regular opportunities for public comment; and

(C) comply with the provisions of the Open Meetings Act.

All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act.

(2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation:

(A) one pharmacist licensed to practice pharmacy in Illinois who is recommended by a statewide organization representing pharmacists;

(B) 4 physicians, recommended by a statewide organization representing physicians, who are licensed to practice medicine in all its branches in Illinois, have knowledge of and adhere to best practice standards, and have experience treating Illinois Medicaid beneficiaries;

(C) at least one clinician who specializes in the prevention and treatment of HIV, recommended by an HIV healthcare advocacy organization;

(D) at least one clinician recommended by a healthcare advocacy organization that serves individuals who are affected by chronic diseases that require significant pharmaceutical treatments;

(E) one clinician representing the Illinois Department; and

(F) one licensed psychiatrist, recommended by a statewide organization representing psychiatrists, who has experience treating Illinois Medicaid beneficiaries.

One non-voting clinician recommended by an association of Medicaid managed care health plans shall serve a term of 3 years on the Board without compensation.

Organizations interested in nominating non-voting clinicians to advise the Board may submit requests to participate to the Illinois Department.

A licensed physician recommended by the Rare Disease Commission who is a rare disease specialist and possesses scientific knowledge and medical training with respect to rare diseases and is familiar with drug and biological products and treatment shall be notified in advance to attend an Illinois Drug and Therapeutics Advisory Board meeting when a drug or biological product is scheduled to be reviewed in order to advise and make recommendations on drugs or biological products.

(d) The Illinois Department shall adopt rules, to be in place no later than January 1, 2020, for the purpose of establishing and maintaining the Board.

(Source: P.A. 101-62, eff. 7-12-19; 102-558, eff. 8-20-21.)