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Provider Notice Issued 03/02/2021

 

Date:    March 2, 2021

 

To:       All Medical Assistance Program Providers

 

Re:      HFS Managed Care Provider Resolution Portal Updates and Reminders

 

 

This notice shares updates and reminders with providers about the HFS Managed Care Provider Resolution Portal.

 

The 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: 

 

o   https://www.illinois.gov/hfs/MedicalProviders/cc/Pages/ManagedCareComplaints.aspx

 

·      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: 

 

o    https://www.cms.gov/Medicare/Medicare 

 

             ·         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:

 

o   No sooner than 30 calendar days after submitting to the MCO's internal process; and, 

o   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.

 

·         All 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 number. 

 

             ·         More information about each MCOs dispute/appeals process​ and tracking numbers is provided at this link:

 

o   https://www.illinois.gov/hfs/SiteCollectionDocuments/MCOProviderDisputeProcessAndTrackingLinksFinal06102020.pdf

 

 ·      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.

 

·       An 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.

 

             ·         Tickets that do not follow the portal guidelines, including incomplete submissions, will be closed. 

 

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

 

 

 

Robert Mendonsa

Deputy Administrator, Care Coordination

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JB Pritzker, Governor • Theresa Eagleson, Director