Date: February 22, 2023
To: All Medical Assistance Program Providers
Re: HFS Managed Care Provider Resolution Portal Updates and Reminders 2023
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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 unresolved 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 here.
- 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. If a provider is not registered to use the portal, the provider will not be able to enter a ticket.
- Registration requests that are complete (all required fields completed, including providing the Medicaid ID) will be processed within a minimum of 2 business days.
- Incomplete registration requests will be denied, and the provider will not be able to enter a ticket until the missing or incomplete information has been provided.
- If a provider or representative is registering multiple providers or facilities, they must use the multiple registration template provided on the portal homepage.
- A Registration Tutorial is also provided on the portal homepage to assist with the Multiple Registration request process.
- Registration requests for 10 or more individuals will result in extended processing timeframes – up to an additional 3 weeks.
- 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 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 strongly encouraged. More information about each MCOs internal dispute process is provided here.
- 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. If the MCO has not provided a response within 30 calendar days of submitting the issue to the MCOs internal dispute process, the provider can proceed with entering the complaint into the Portal.
- 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 process. Providers must enter this MCO assigned tracking number in the Provider Resolution Portal when completing a complaint ticket. Providers must contact the MCO to receive a tracking number. Complaints submitted without the MCO assigned tracking number will be closed. More information about each MCOs dispute process and how to request a tracking number is provided here.
- 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. An MCO and Provider may also have discussions about a complaint during the MCO 30 calendar day resolution period.
- Tickets that do not follow the portal guidelines, including incomplete submissions, will be closed. Closed tickets will not be re-opened or re-started. The provider will need to submit a new ticket with all information included.
- 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 encourage providers to review and apply 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.
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
