DHFS-SRVCE AUTHORIZATION PGRAM

Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately.

• Dagmara AvelarD
• Kelly M. CassidyD