IL HB4893

Requires the Department of Healthcare and Family Services to incorporate minimum standards for behavioral health pre-payment and post-payment reviews into Managed Care Organization (MCO) contracts, effective for services on and after January 1, 2027.

Mandates MCOs provide at least 45 calendar days written notice before beginning a review, with documentation requests limited to records within 12 months of the review initiation date, and providers given at least 45 days to respond.

Establishes provider rights to dispute records requests deemed overly broad, duplicative, or unduly burdensome, with disputes pausing payment holds pending resolution and allowing escalation to the Department if unresolved.

Restricts use of statistical extrapolation for overpayment determinations to cases where a documented educational intervention has first failed to correct the billing error, requiring statistically valid methodology and written notice to providers.

Requires standardized communication protocols including entry and exit communications, specific MCO contact information, fraud disclosure in initial notices, and protections against adverse actions for providers exercising dispute rights.