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Frazzled by a Medicaid MCO Claim? State Announces New Dispute Process
Posted on: 8/30/2017

If you are enrolled with an Illinois Medicaid Managed Care Organization (MCO), take note of new procedures that took effect August 9 for resolving certain disputed medical assistance claims:

Medicaid offers a secure complaint portal to assist you in resolving any issue with an MCO.

But you must first attempt to work out the problem with the MCO before submitting a complaint.

  • If payment for a medically necessary covered service is denied by an MCO based on inaccurate or recently updated enrollment information, the claim will be paid once the health care professional proves that services rendered met all Medicaid requirements or verifies the patient's medical assistance enrollment on the date of service (via any of the systems that Medicaid uses for electronic enrollment verification).

  • If the MCO denies payment due to lack of prior authorization, the health care professional must document that either:
    • Prior authorization was approved by a previous MCO;
    • Prior authorization was approved by another entity with which the patient was enrolled; or
    • A previous entity did not require prior authorization for that service.

The updated regulations also establish a 180-day timely filing period to start the claims resolution process, beginning on the date a health care professional is notified of a claim denial.

But don't get your hopes up regarding reimbursement timeliness – this process won’t help address existing payment delays associated with the state’s financial woes. The State of Illinois' unpaid bill backlog for medical care provided through MCOs currently stands at more than $3 billion!

Questions? Please contact the ISMS Advocacy Team at 800-782-4767 ext. 1470, or by email.

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