Illinois Statutes Chapter 305. Public Aid § 5/5-30.12. Managed care claim rejection and denial management

(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.