How Do You File a Complaint About a Medicaid MCO?

December 1, 2023

In our last edition of Physician Advocate, we covered filing complaints with the Illinois Department of Insurance (IDOI). As a follow-up, here’s a deep dive into a different process for filing a complaint when it comes to Medicaid managed care plans.

Approximately three-quarters of Medicaid patients in Illinois are covered by a Medicaid managed care organization (MCO). While MCOs are subject to their own operating requirements, many – but not all – mirror laws and regulations that apply to private plans regulated by the IDOI.

However, MCOs are awarded contracts by the Illinois Department of Healthcare and Family Services (HFS), which has regulatory and enforcement authority over the contracted plans.

Therefore, physicians and other health professionals that have complaints with an MCO are required by HFS to first use the individual plan’s dispute resolution process before filing an official complaint with HFS.

If efforts to resolve the dispute directly with the MCO are unsuccessful, HFS operates a Provider Resolution (Complaint) Portal to assists with complaints related to claims and payment, contracting, coverage and service denials, eligibility, prior authorization and other issues. Healthcare professionals must be registered to use this portal. (Learn how to register – scroll down to “Individual and Multiple Provider/Facility Registration Instructions.”)

Decisions rendered by HFS in a dispute are final. Medicaid MCO patients must contact their health plan to both file a complaint or request an appeal.

Learn more with ISMS’ Issue Brief, Health Insurance Complaints?

Questions? Please contact the ISMS Health Policy Research and Advocacy team by email.