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Illinois Dept. of Healthcare and Family Services opens Medicaid MCO complaint portal

2/08/2017 - The Department of Healthcare and Family Services (HFS) has launched a secure electronic web-based portal to assist providers statewide in resolving issues with Illinois Medicaid Managed Care Organizations (MCOs). HFS recognizes the importance of providers having a mechanism for reporting and resolving issues encountered with an individual Medicaid MCO when these issues cannot be resolved using existing processes designated by the MCO. A major goal of the new MCO provider complaint portal is to facilitate prompt and fair resolution of disputes between MCOs and providers. Issues impacting immediate access to care will be expedited.

The new MCO provider complaint portal does not replace issue reporting and escalation processes already in place between providers and an MCO. Prior to submitting a complaint through the new online portal, issues must already have been submitted to and reviewed by the MCO in question. If HFS determines a complaint was submitted to the Department prior to the MCO being afforded an opportunity to resolve it directly with the provider, the complaint will be immediately closed.

Providers should carefully identify which representatives within their provider organizations will be designated to use this complaint system for unresolved issues. The name of the provider representative submitting the complaint will be shared with the MCO, and outcomes will be reported only to the provider representative whose email is entered into the system with the complaint. HFS will collect and publically report the volume of complaints received and resolved by provider type, MCO, and other categories.

HFS staff will follow Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy procedures when using this secured site and providers must do so as well as a condition of use. Providers are able to upload protected health information to the secure provider complaint portal.  If the complaint relates to a specific individual or claim, or group of related claims, providers must share the relevant member name(s), HFS 9-digit Recipient Identification Number(s), and date(s) of service. Each complaint should be for a single topic for a single MCO; please do not combine several issues or designate more than one MCO on the same complaint.

The link to the complaint portal may be found on HFS’ Care Coordination Webpage, or may be accessed directly from the HFS Managed Care Provider Complaints webpage. The portal is available for immediate use.  Please note that this new system is designed specifically for issues enrolled providers have with Illinois Medicaid MCOs. Provider complaints regarding the resolution of Medicaid Fee-for-Service issues should continue to be directed to HFS at 877-782-5565.