305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-30.10)

Sec. 5-30.10. Electronic report submission. To preserve the quality of data and ensure productive oversight of Medicaid managed care organizations, all regular reports required, either by contract or statute, to be collected by the Department from managed care organizations shall be collected through a secure electronic format and medium as designated by the Department. The Department shall consider concerns raised by the contractor about potential burdens associated with producing the report. Ad hoc reports may be collected in alternative manners.

(Source: P.A. 100-1105, eff. 8-27-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-30.11)

Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when (1) ordered by a physician licensed to practice medicine in all its branches or a psychologist licensed by the Department of Financial and Professional Regulation and (2) evaluated by a behavior analyst as recognized by the Department or licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019. Pursuant to the flexibilities allowed by the federal Centers for Medicare and Medicaid Services to Illinois under the Medical Assistance Program, the Department shall enroll and reimburse qualified staff to perform applied behavior analysis services in advance of Illinois licensure activities performed by the Department of Financial and Professional Regulation. These services shall be covered if they are provided in a home or community setting or in an office-based setting. The Department may conduct annual on-site reviews of the services authorized under this Section. Provider enrollment shall occur no later than September 1, 2023.

(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22; 103-102, eff. 7-1-23.)

(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.)