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Provider Notice Issued 03/02/2021
Date: March2, 2021
To: All Medical Assistance Program Providers
Re: HFS Managed Care Provider Resolution Portal Updatesand Reminders
This notice shares updates and reminderswith providers about the HFS Managed Care Provider Resolution Portal.
TheIllinois Department of Healthcare and Family Service’s (Department) ManagedCare Provider Resolution Portal is used specifically for issues providers havewith Illinois Medicaid Managed Care Organizations (MCOs) participating in theManaged Care programs. Provider complaints regarding the resolution ofMedicaid fee-for-service issues should continue to be directed to theDepartment at 877-782-5565.
· All providers are required to submit unresolved disputes with an MCOvia 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 complaintsrelative to the Medicaid portion only, not Medicare. This alsoincludes denials for a Medicare-covered service for a dually eligibleclient. Medicare only complaints submitted in the portal will be closed.In working with the MCO on Medicare issues, providers should refer to theCenters for Medicare and Medicaid Services (CMS) Medicare website for billinginformation, fee schedules, and appeals and grievances guidelines:
o https://www.cms.gov/Medicare/Medicare
· Providers or designated billingstaff must first register with the portal before a complaint can be submitted.Portal registration materials and instructions for individual and multiplefacility sites are available on the portal home page.
· The Department requires that providers first use the MCO internaldispute/appeals process to attempt to resolve a complaint. This means providersmust follow and exhaust all processes provided by MCOs to resolve adispute, including peer-to-peer disputes, before submitting a complaint throughthe portal. Communicationbetween the provider and the MCO during the initial dispute resolution periodis encouraged. Disputes submitted to the MCO internal disputeresolution process may be submitted to the portal:
o No sooner than30 calendar days after submitting to the MCO's internal process; and,
o No later than60 calendar days after submitting to the MCO’s internal process.
Providers must follow the 30/60 calendarportal ticket submission timeframes. Tickets that do not follow the 30/60calendar day timeframes will be closed.
· AllMCOs are required to assign the provider a tracking number for each complaintsubmitted through their internal dispute/appeals process. Providers must enterthis MCO assigned tracking number in the Provider Resolution Portal whencompleting a complaint ticket. Complaints submitted without a tracking numberwill be closed. Providers must contact the MCO to receive a trackingnumber.
· More information about each MCOs dispute/appeals process and trackingnumbers is provided at this link:
· Any complaint that involves failure to obtain a priorauthorization where required will be closed. If the provider receiveda prior authorization, that information must be provided to the MCO as part ofthe MCO’s internal dispute process. Note: receipt of a priorauthorization does not guarantee payment.
· The Department strongly encourages providers to review the ComprehensiveBilling Manual developed by the Illinois Association of Medicaid Health Plans(IAMHP). The Department has approved these guidelines for posting, and they include MCOcontacts, clearinghouse information, and more.
· AnMCO can request additional information from a provider within five business daysof receiving the ticket in the portal. The provider must provide (submit)the additional information requested in the portal within 5 business days ordemonstrate that this information was previously shared with the MCO. If the provider does not respond within the 5 businessdays, the ticket will be closed. Providers are encouraged to read and respondto portal email notifications timely.
· Ticketsthat do not follow the portal guidelines, including incomplete submissions, willbe closed.
Questions regarding the portal, orprovider portal registration, can be submitted to the Bureau of Managed Careand Portal team at HFS.PortalInquiries@Illinois.gov
Robert Mendonsa
Deputy Administrator, CareCoordination