HB2730 Summary

• Provides providers who exhaust internal appeals with MCOs the right to request external independent third-party review of MCO decisions denying health care services or claim reimbursement.

• Requires MCO final decision letters to include: statement that internal appeals are exhausted, notification of external review entitlement, timeframe to request review, and mailing address for initiating review.

• Allows parties to appeal external review decisions through administrative hearing within 30 days, with final Director decisions reviewable under Administrative Review Law; establishes fees up to $1,000 to be paid by non-prevailing party.

• Mandates MCOs pay emergency services and post-stabilization services at Illinois Medicaid fee-for-service rates including all applicable adjustments, with attending physician's stabilization determination binding on the MCO.

• Requires Department to publish quarterly MCO performance metrics covering claims payment, prior authorizations, grievances, credentialing, and customer service; effective 120 days after enactment.