MEDICAID-MCO BEHAVIORAL HLTH

Illinois General Assembly - Full Text of HB4893

Select Language

×

The Illinois General Assembly offers the Google Translate™ service for visitor convenience. In no way should it be considered accurate as to the translation of any content herein.

Visitors of the Illinois General Assembly website are encouraged to use other translation services available on the internet.

The English language version is always the official and authoritative version of this website.

NOTE: To return to the original English language version, select the "Show Original" button on the Google Translate™ menu bar at the top of the window.

Choose Language

English

Afrikaans

Albanian

Arabic

Armenian

Azerbaijani

Basque

Bengali

Bosnian

Catalan

Croatian

Czech

Danish

Dutch

Esperanto

Estonian

Filipino

Finnish

French

Galician

Georgian

German

Greek

Gujarati

Haitian Creole

Hausa

Hawaiian

Hebrew

Hindi

Hungarian

Icelandic

Indonesian

Interlingua

Interlingue

Inuktitut

Irish

Italian

Japanese

Javanese

Kannada

Khmer

Korean

Latin

Latvian

Lithuanian

Luxembourgish

Macedonian

Malagasy

Malayalam

Maltese

Maori

Marathi

Myanmar

Nepali

Norwegian

Odia

Pashto

Punjabi

Romanian

Russian

Samoan

Sango

Sanskrit

Sardinian

Sindhi

Sinhala

Slovak

Slovenian

Somali

Southern Sotho

Spanish

Sundanese

Swahili

Swedish

Tamil

Telugu

Thai

Tigrinya

Tonga

Turkish

Ukrainian

Urdu

Vietnamese

Welsh

Xhosa

Yiddish

Yoruba

Zulu

Powered by
Translate

Close

Illinois General Assembly

Top Navigation Bar

Translate

Learn

Select General Assembly

Search the 104th General Assembly

Enter search terms for legislation, members, committees, or schedules.

ILGA.GOV

LEGISLATION & LAWS

Bills & Resolutions

Public Acts

Illinois Compiled Statutes

Illinois Constitution

Search Legislation

Glossary

Guide

Reports & Inquiry

Legislative Reports

Special Reports

FTP Site

Legislator Lookup

Capitol Complex Phone Numbers

Rules & Regulations

Illinois Register

Administrative Rules

Senate

Members

Schedules

Committees

Request for Remote Testimony

Journals

Transcripts

Rules

Audio/Video

FOIA Information

Senate Employment Opportunities

Media Guidelines

House

Members

Schedules

Committees

Submit testimony for House Committees

Journals

Transcripts

Rules

Audio/Video

FOIA Information

House Employment Opportunities

Log In

Mobile Top Bar

Search the 104th General Assembly

Enter keywords to search the Illinois General Assembly website.

Full Text of HB4893

Home

Legislation

Full Text

HB4893 - 104th General Assembly

Bill Status

Full Text

Votes

Witness Slips

Select Menu

Bill Status

Full Text

Votes

Witness Slips

Printer Friendly Version

Introduced

Printer Friendly Version

Introduced

Open PDF

104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB4893

Introduced , by Rep. Lindsey LaPointe

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-30.19 new

Amends the Medical Assistance Article of the Illinois Public Aid
Code. Provides that the Department of Healthcare and Family Services must
incorporate minimum standards governing behavioral health pre-payment and
post-payment reviews into MCO contracts effective for all services covered
on and after January 1, 2027. Requires the Department to develop or adopt
behavioral health-specific pre-payment and post-payment review guidelines
and incorporate such guidelines by reference into MCO contracts. Provides
that the Department-issued guidelines must: (1) define the documentation
and clearly specify the discrete data elements that may be requested prior
to and during a pre-payment or post-payment review, and applicable
response timeframes, ensuring that all requests are specific, reasonable,
and directly tied to the review objectives; (2) identify regulatory,
statutory, and contractual standards applicable to behavioral health
services; (3) establish uniform evaluation criteria and checklists; and
(4) be publicly available and updated as necessary. Contains provisions on
MCO contracts and required contract terms; pre-payment and post-payment
review processes and notice requirements; timeframes for providers to
respond to a documentation request; communication protocols; contract
transparency and extrapolation from a statistical sampling of claims; the
timeliness and closure of claims reviews; submission methods; reviewer
qualifications; and enforcement. Effective immediately.
LRB104 18033 KTG 31472 b

A BILL FOR

HB4893
LRB104 18033 KTG 31472 b
1

AN ACT concerning public aid.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 5.
The Illinois Public Aid Code is amended by
5
adding Section 5-30.19 as follows:

6

(305 ILCS 5/5-30.19 new)
7

Sec. 5-30.19.
MCO behavioral health pre-payment and
8
post-payment reviews.
9

(a) The General Assembly finds that:
10

(1) Behavioral health providers serving Medicaid
11

enrollees are essential to ensuring timely access to
12

mental health and substance use disorder services across
13

the State of Illinois.
14

(2) MCOs contracted with the Department of Healthcare
15

and Family Services conduct pre-payment and post-payment
16

reviews to ensure program integrity and compliance with
17

applicable requirements.
18

(3) Providers have reported significant procedural
19

challenges in the conduct of such reviews, including
20

excessive administrative burden, unclear documentation
21

standards, inconsistent findings, inadequate
22

communication, and lack of transparency regarding review
23

criteria and methodologies.

HB4893
- 2 -
LRB104 18033 KTG 31472 b
1

(4) Requests for extensive historical records, unclear
2

or inconsistent audit standards, delayed issuance of
3

findings, and insufficient time to respond to
4

determinations undermine provider capacity and may
5

negatively impact service delivery.
6

(5) Transparency, consistency, and standardization in
7

review processes are essential to promoting compliance,
8

reducing unnecessary administrative burden, and ensuring
9

fair and equitable treatment of providers.
10

(6) State-issued, service-specific review guidelines,
11

reasonable timeframes, and clear communication protocols
12

are commonly used by accreditation bodies and federal
13

programs to promote objective and uniform oversight.
14

(b) The Department must incorporate minimum standards
15
governing behavioral health pre-payment and post-payment
16
reviews into MCO contracts effective for all services covered
17
on and after January 1, 2027.
18

(c) As used in this Section:
19

"Behavioral health services" means mental health services,
20
substance use disorder services, and co-occurring disorder
21
services covered under the medical assistance program.
22

"Managed Care Organization" or "MCO" means an entity
23
contracted with the Department to provide or arrange medical
24
assistance services on a capitated basis, including Managed
25
Care Community Networks.
26

"Managed Care Community Network" or "MCCN" means an

HB4893
- 3 -
LRB104 18033 KTG 31472 b
1
entity, other than a health maintenance organization, that is
2
owned, operated, or governed by providers of health care
3
services within Illinois and that provides or arranges
4
primary, secondary, and tertiary managed health care services
5
under contract with the Department exclusively to persons
6
participating in programs administered by the Department.
7

"Pre-payment review" means a review, whether titled a
8
review or not, conducted prior to payment to determine whether
9
submitted claims meet coverage, documentation, and billing
10
requirements.
11

"Post-payment review" means a review, whether titled a
12
review or not, conducted after payment to assess compliance
13
with applicable requirements.
14

"Provider" means a behavioral health provider, including a
15
Community Mental Health Center, Behavioral Health Clinic,
16
Certified Community Behavioral Health Clinic, or Substance Use
17
Treatment and Recovery Center, enrolled in the medical
18
assistance program and contracted with or reimbursed by an
19
MCO.
20

"Extrapolation" means the application of review findings
21
from a sampled set of claims to a larger universe of claims for
22
purposes of determining overpayments or recoupments.
23

(d) Applicability. This Section applies solely to
24
behavioral health pre-payment and post-payment reviews
25
conducted by MCOs under contract with the Department to
26
fulfill contractual requirements for program integrity and

HB4893
- 4 -
LRB104 18033 KTG 31472 b
1
compliance.
2

(e) Contract requirements. The Department must require, as
3
a condition of any contract with an MCO, that the organization
4
comply with the requirements of this Section with respect to
5
behavioral health services.
6

(f) Standardized review guidelines. The Department must
7
develop or adopt behavioral health-specific pre-payment and
8
post-payment review guidelines and incorporate such guidelines
9
by reference into MCO contracts. MCOs must conduct reviews in
10
accordance with the Department-issued guidelines. The
11
guidelines must:
12

(1) define the documentation and clearly specify the
13

discrete data elements that may be requested prior to and
14

during a pre-payment or post-payment review, and
15

applicable response timeframes, ensuring that all requests
16

are specific, reasonable, and directly tied to the review
17

objectives;
18

(2) identify regulatory, statutory, and contractual
19

standards applicable to behavioral health services;
20

(3) establish uniform evaluation criteria and
21

checklists; and
22

(4) be publicly available and updated as necessary.
23

(g) Reasonable scope and timeframes. MCO contracts must
24
provide the following:
25

(1) MCOs may conduct pre-payment or post-payment
26

reviews only when supported by data indicating a

HB4893
- 5 -
LRB104 18033 KTG 31472 b
1

reasonable possibility of error, fraud, waste, or abuse or
2

as requested by the State.
3

(2) MCOs must notify providers selected for
4

pre-payment or post-payment review by individual written
5

notice to the correspondence address identified in IMPACT
6

with confirmed receipt by provider, stating the specific
7

reason for selection, at least 45 calendar days prior to
8

beginning the review.
9

(3) If the basis for selection of a provider for
10

review is comparative data, the MCO must provide the data
11

on how the provider varies significantly from other
12

providers in the same provider type, service specialty,
13

jurisdiction, or locality.
14

(4) Documentation requests must clearly specify the
15

records being requested and the timeframe for provider
16

response.
17

(5) Requests for documentation are limited to records
18

for dates of service within 12 months of the date of the
19

initiation of the review.
20

(6) Providers are afforded a minimum of 45 calendar
21

days from the date of the request to submit additional
22

documentation, with extensions permitted for good cause.
23

(7) MCOs must permit electronic or other least
24

burdensome methods for submission of requested records.
25

(8) The date on which documentation is received in a
26

secure electronic system is the official date of receipt

HB4893
- 6 -
LRB104 18033 KTG 31472 b
1

for purposes of compliance with submission deadlines.
2

(h) Provider right to dispute records requests.
3

(1) A provider may dispute or appeal any records
4

request issued by an MCO if the provider reasonably
5

believes that the request is:
6

(A) overly broad;
7

(B) duplicative;
8

(C) unduly burdensome; or
9

(D) not reasonably related to verification of
10

payment, medical necessity, quality of care, or
11

compliance with applicable law or contract
12

requirements.
13

(2) The provider must notify the MCO in writing within
14

14 calendar days of receipt of the records request,
15

specifying the basis for the dispute. Upon receipt of such
16

notice, the MCO must pause the records request, and any
17

associated payment holds pending resolution of the
18

dispute.
19

(3) The MCO must respond in writing within 14 calendar
20

days of receipt of the provider's dispute notice, either:
21

(A) narrowing the scope of the records request; or
22

(B) providing a written justification
23

demonstrating the necessity of the requested
24

documentation.
25

(4) If the dispute is not resolved between the
26

provider and the MCO, the provider may escalate the matter

HB4893
- 7 -
LRB104 18033 KTG 31472 b
1

to the Department for review and determination. The MCO
2

must comply with the Department's final determination
3

regarding the dispute.
4

(5) Providers must not be subject to any adverse
5

action, payment delay, sanctions, or contract termination
6

solely for exercising the right to dispute or appeal a
7

records request in accordance with this Section.
8

(i) Communication protocols. MCO contracts must require
9
standardized communication protocols, including that:
10

(1) MCOs will clearly state in their initial
11

communication to providers if a post-payment review is
12

based on suspected fraud.
13

(2) MCOs will conduct entry and exit communications
14

with providers to clearly convey the review scope,
15

expectations, preliminary findings, compliance status, and
16

next steps, ensuring consistent messaging throughout the
17

review process.
18

(3) MCOs will provide advance written notice,
19

delivered electronically, to providers of documentation
20

requests for any pre-payment or post-payment review,
21

including the applicable review period. Paper mail may be
22

used as a secondary method of delivery through carriers
23

that meet the following requirements:
24

(A) Standard Postal Services - any Protected
25

Health Information (PHI) that is sent via USPS, UPS,
26

or FedEx must be sent in sealed envelopes, and must

HB4893
- 8 -
LRB104 18033 KTG 31472 b
1

utilize a package tracking mechanism.
2

(B) Certified Mail - proof of delivery and a
3

recipient signature of any PHI sent via this method is
4

required as a means of providing additional security
5

and accountability.
6

(4) All notifications and requests for additional
7

documents must include specific MCO contact information
8

for provider communication regarding the pre-payment or
9

post-payment review.
10

(j) Transparency of findings and extrapolation. MCO
11
contracts must require that:
12

(1) Providers receive written notification of final
13

review findings, including clear references to applicable
14

regulatory or contractual citations, an explanation of the
15

rationale for each finding, guidance on required next
16

steps or corrective actions, and information regarding the
17

process and timelines for appealing the findings.
18

(2) All findings and related written communications
19

are clear, consistent, and non-contradictory to prevent
20

confusion or conflicting conclusions.
21

(3) Extrapolation from a statistical sampling of
22

claims may only be used after a documented educational
23

intervention has failed to correct the payment error. As
24

used in this paragraph, "documented educational
25

intervention" means:
26

(A) targeted communication or training provided to

HB4893
- 9 -
LRB104 18033 KTG 31472 b
1

the provider regarding identified billing, coding, or
2

documentation errors;
3

(B) clear explanation of the correct billing or
4

documentation practices required; and
5

(C) written documentation that such education was
6

provided to the provider, including the date, format,
7

and content of the intervention.
8

(4) Where an MCO elects to extrapolate findings from a
9

sample to a larger universe of claims, the MCO must:
10

(A) ensure that any extrapolation methodology is
11

statistically valid;
12

(B) provide the provider with written notice of
13

the extrapolation methodology and sample used; and
14

(C) maintain records sufficient to demonstrate
15

compliance with this Section, including documentation
16

of the educational intervention and rationale for
17

extrapolation.
18

(5) The provider has the right to dispute or appeal
19

the use of extrapolation and the resulting overpayment
20

determination under the contract's grievance and appeal
21

process.
22

Providers must not be subject to adverse action,
23

payment delay, or sanctions solely for exercising their
24

right to dispute or appeal extrapolation.
25

(6) The provider may escalate unresolved disputes
26

regarding extrapolation to the Department for review, and

HB4893
- 10 -
LRB104 18033 KTG 31472 b
1

the MCO must comply with the Department's final
2

determination.
3

(k) Timeliness and closure. MCO contracts must require
4
that:
5

(1) Claims be reviewed and findings issued within 60
6

calendar days of receiving the documentation initially
7

requested from the provider, to allow providers sufficient
8

opportunity to respond and implement corrective actions.
9

(2) Providers are afforded 60 calendar days to review
10

and respond to findings, clearly specifying the basis for
11

disputes of specific findings.
12

(3) Within 60 calendar days of receiving the
13

provider's response to findings, MCOs must respond and
14

supply a report addendum with a determination of whether
15

the response warrants additional investigation and
16

discussion.
17

(4) Upon completion of the review, a formal written
18

notice of compliance or closure be issued to the provider.
19

(l) Submission methods. MCO contracts must require the use
20
of the least burdensome and lowest-cost method of record
21
submission, including secure electronic methods, when
22
available.
23

(m) Compliance-oriented approach. MCO contracts must
24
require an approach emphasizing education, technical
25
assistance, and corrective action prior to punitive
26
enforcement, except in cases involving fraud or willful

HB4893
- 11 -
LRB104 18033 KTG 31472 b
1
misconduct.
2

(n) Qualifications of reviewers. MCOs must ensure that
3
reviewers who perform pre-payment and post-payment reviews
4
have experience with Illinois-specific behavioral health care
5
assessment, service delivery, billing, and documentation and
6
receive training consistent with pre-payment and post-payment
7
review requirements in managed care contracts.
8

(o) Enforcement. Failure by an MCO to comply with this
9
Section constitutes a breach of contract subject to remedies
10
available to the Department.

11

Section 99.
Effective date.
This Act takes effect upon
12
becoming law.

Footer

Disclaimer

This site is maintained for the Illinois General Assembly by the
Legislative Information System, 705 Stratton Building, Springfield, Illinois 62706.

Contact ILGA Webmaster

ILGA.gov uses cookies to ensure you get the best experience on our website. By continuing to browse ILGA.gov you consent to our use of cookies.
Read About Cookies

ILGA.GOV

2026 ILGA.gov | All Rights Reserved |
ADA

|
Disclaimers
|
Learn

This site is maintained for the Illinois General Assembly by the
Legislative Information System, 705 Stratton Building, Springfield, Illinois 62706.
Contact ILGA Webmaster

ILGA.gov uses cookies to ensure you get the best experience on our website. By continuing to browse ILGA.gov you consent to our use of cookies.
Read About Cookies

ILGA.GOV

2026 ILGA.gov | All Rights Reserved |
ADA

|
Disclaimers
|
Learn