MMAI-PAYMENT CLAIMS-MEDIATION

Amends the Illinois Public Aid Code. In a provision concerning non-emergency prior approvals and appeals under the Medicare-Medicaid Alignment Initiative Demonstration Project, requires Managed Care Organizations (MCOs) to have a method of receiving prior approval requests 24 hours a day, 7 days a week, 365 days a year from (rather than for) nursing home residents, physicians, or providers (rather than nursing home residents). Provides that in a non-emergency situation, in the event a resident's physician orders a service, treatment, or test that is not approved by the MCO, the enrollee, physician, or provider may utilize an expedited appeal to the MCO (rather than the physician and the provider may utilize an expedited appeal to the MCO). Requires the MCO to notify all individuals who file an expedited appeal of the MCO's decision within 24 hours after receipt of all required information. Adds provisions concerning payment of claims submitted by a provider to a MCO, including: (i) the time period within which a claim must be reviewed and paid; (ii) MCO notification regarding the corrective action needed to permit payment of a rejected or denied claim; (iii) MCO notification on coding and documentation requirements; and (iv) the establishment of a claims mediation process to mediate rejected or denied claims.