305 ILCS 5/5-30.19: MCO behavioral health post-payment reviews.

(a) In this Section:

"Extrapolated" shall be used as "extrapolation" is used in 89 Ill. Adm. Code 140.30(b) or any successor rule.

"Managed care organization" or "MCO" has the meaning given to that term in Section 5-30.1 of this Code.

"Post-payment review" means an examination that occurs after payment is made by an MCO for a selected claim to determine whether the initial determination for payment was appropriate.

"Provider" means a community mental health center, behavioral health clinic, certified community behavioral health clinic, or substance use treatment and recovery center that is enrolled in the medical assistance program and contracted with or reimbursed by an MCO.

(b) Beginning July 1, 2027, when conducting post-payment reviews of providers, MCOs must establish guidelines that follow the Department's guidance. The Department's guidance shall mandate that MCOs:

(1) Clearly define the documentation and the response time frames ensuring that all requests are directly tied to the review objectives. Documentation and response time frames do not apply to methods necessary for fraud, waste, and abuse post-payment reviews, including, but not limited to, unscheduled or unannounced site visits and database checks.

(2) Identify regulatory, statutory, or contractual authority and standards for conducting the post-payment review.

(3) Clearly define evaluation criteria and provide documentation checklists.

(4) Establish a process to dispute MCO record requests not made in conformance with this Section.

(5) Establish a process and clarify the instances that allow for entry and exit communications with providers to clearly convey the review scope, expectations, preliminary findings, compliance status, and next steps, ensuring consistent messaging throughout the review process.

(6) Establish qualifications of reviewers with relevant knowledge, experience, and training.

(7) Provide the data on how the provider varies significantly from other providers in the same provider type, service specialty, jurisdiction, or locality, if the basis for selection of a provider for review is comparative data except where fraud, waste, and abuse processes and procedures prevent disclosure.

(8) Clearly outline communication protocols, including advance written notice, delivered electronically, by MCOs to providers of documentation requests with an allowance for reasonable response times and except for instances where fraud, waste, and abuse processes and procedures prevent advance notice, including, but not limited to, unscheduled or unannounced site visits.

(9) Upon completion of the review, issue a formal written notice of compliance or closure to the provider. The final review findings shall include clear references to applicable regulatory or contractual citations, an explanation of the rationale for each finding, guidance on required next steps or corrective actions, and information regarding the process and timelines for appealing the findings.

(10) Use the least burdensome and lowest-cost method of record submission, including secure electronic methods, when available. The date on which documentation is received in the electronic communication shall be the official date of receipt. All communication protocols shall be compliant with privacy and security laws.

(11) Issue findings and related written communications in a clear, consistent, and non-contradictory manner to prevent confusion or conflicting conclusions.

(12) Disclose the methodology supporting any extrapolated finding.

(c) The MCO shall post the guidelines and any updates on its publicly available website.

(d) Providers must not be subject to any adverse action, payment delay, sanctions, or contract termination solely for exercising the right to dispute a records request in accordance with this Section, except for matters involving allegations of fraud, waste, or abuse.

(e) Nothing in this Section shall be construed to conflict with State or federal program integrity law, regulations, guidance, processes, or procedures.