Working with Medicaid Managed Care Organizations

HFS opens Medicaid MCO complaint portal for Providers.  Learn more and use this portal when a Medicaid Managed Care Organization is not resolving an issue for your patients. 

Information on NEW Medicaid MCO rollout coming January 1, 2018

Important update for Central Illinois Medicaid providers:  Mandatory Managed Care temporarily suspended in this region

Provider Notice for ICP Population The affected counties for the ICP population include Champaign, Christian, DeWitt, Ford, Logan, Macon, McLean, Menard, Piatt, Sangamon and Vermilion. 

Provider notice for the FHP Population The affected counties for the FHP population include Champaign, Christian, DeWitt, Ford, Logan, Macon, Menard, Piatt, Sangamon and Vermilion

As of Jan. 1, 2017 and until we hear otherwise from HFS, those Medicaid recipients in the Central IL region not with Molina can still access services (fee-for-service) through any provider that takes Medicaid and is willing to take them. If Medicaid recipients are having a hard time finding a provider that will accept their Medicaid card (fee-for-service), they should call Illinois Health Connect at 877-912-1999 (TTY: 1-866-565-8577).


Resource:  The Illinois Dept. of Healthcare and Family Services Medicaid Managed Care user manual

Physician Survey Results:  View the survey results report from the Medicaid Managed Care Survey sent to active members of IAFP, Illinois State Medical Society, Illinois Chapter of the American Academy of Pediatrics and the Illinois Psychiatric Society. 

Navigating Medicaid Managed Care Webinar 4/28/16 presented by Alvia Siddiqi, MD, FAAFP - Click here for slides

Illinois Association of Medicaid Health Plans -

All MCOs have their own formulary which is accessible on their own websites:

Answers to commonly asked questions & concerns

What is the next step if the MCO covered formulary drug is known not to be effective for patient?
If a drug is not known to be effective, the provider can request a different drug in the same class.  It may require prior authorization.
How can physicians be notified timely of patient plan changes?
Physicians should check MEDI for member’s most recent MCO.  The Illinois Client Enrollment Services (ICES) sends eligibility files to HFS daily and it takes approximately 24 hours (may take longer over a weekend) to update the HFS system and MEDI.  If physicians find that MEDI is incorrect, please notify HFS including details such as a print out of the MEDI screen.
How can physicians get more frequent up to date information from care coordinators and care plans?
Care coordinators should be sending care plans to the PCPs via provider portal, fax, or mail.  If you are not receiving those care plans or if the care plans are incorrect or inaccurate, contact the MCO Medical Director:
Aetna – Bruce Himelstein, MD,
BCBS – Anita Steward, MD,
CCAI – Tariq Butt, MD,
CountyCare – Elmer Abbo, MD –
FHN – Susan Oyetunde, MD,
Harmony – Traci Ferguson, MD –
Health Alliance – Robert Parker, MD –
HealthSpring – Melanie Hunter, MD –
Humana – Neal Fischer, MD –
IlliniCare – Angela R. Perry, MD –
Meridian – Cynthia Sanders, MD –
Molina – Traci Powell –
Billing is being done on two different systems. Why this is the case?
APL should bill on UBO40, Non-APL on CMS1500.
MCOs have a timely payment provision in their contract as follows:
Contractor must pay 90 percent (90%) of all Clean Claims from Providers for Covered Services within thirty (30) days following receipt.  Contractor must pay 99 percent (99%) of all Clean Claims from Providers for Covered Services within ninety (90) days following receipt.  Claims for care of babies seen in the first 90 days who should still be covered under mother’s MCO. MCO representatives recommended proactively reaching out to the MCOs for denied claims. Physicians requested that MCOs reach out to them proactively as well when patterns of repeated denied claims are recognized. MCOs have access to all HFS handbooks and should be familiar with the Healthy Kids Handbook.  If you have a situation where an MCO denies a covered service, go to the Provider relations contacts on the HFS website.
How can we address the problem of emergency room claims denials by MCOs?
MCO representatives noted that all emergency room claims are mandatorily covered by law. Specific examples of denials should be presented to MCOs so they can determine the cause of those denials. Out of network emergencies are covered at the Medicaid FFS rate.
Could general guidelines on performance incentive information be provided?
This is specific to each health plan; however, it should be included in the contract MCOs have with their providers.  If there are any questions please contact health plan directly. Meetings and trainings are typically provided by the MCO provider services. This information cannot be shared publicly due to antitrust concerns.
Credentialing is sometimes lengthy and difficult and is different for each MCO. Could a grace period be offered as HFS has?
Due to NCQA accreditation, credentialing cannot be backdated; however MCOs do have workarounds in place such as provisional credentialing. CAQH is the preferred system for submitting credential paperwork and can greatly ease process.
How does mental health parity law apply to MCOs?
Mental health parity does not apply to ACEs and CCEs, however as those plans are in transition to an MCO partnership or MCCN, parity will apply after the transition. Parity is based on percentage of the HFS Medicaid rate, a minimum rate of 100% of Medicaid rate is in compliance.
There is a concern that behavioral health is not being integrated with medical care.
Some health plans have a model that includes integrating behavioral health specialist into a medical home.  Several health plans have contracted with FQHCs that have behavioral health services integrated.    
Inpatient addiction services are not being covered, or covered as observation only.
Inpatient addiction services are covered by the Medicaid health plans.    If providers are experiencing problems getting the health plans to cover these services, the Department can look into the issues but will need examples (member names, recipient identification numbers, dates of service, procedure code/service provided, and health plan(s) involved).