Sec. 5-30.12. Managed care claim rejection and denial management.

395 words·~2 min read·/il/chapter-305/act-5/5-30-12

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(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.