Bill
SB 3163
The bill standardizes provider credentialing via CAQH, adds provider network and enrollment support, and clarifies recoupment transparency for Medicaid MCOs.
Title: DHFS-MANAGED CARE PROTECTIONS
Jurisdiction: Illinois
Introduced: February 2, 2026
Sponsorship: Sen. David Koehler (Co-sponsor: Dave Koehler)
Effective Date: January 1, 2027
Purpose
- To enhance protections and streamline credentialing, enrollment, and communications between health care providers and managed care organizations (MCOs) participating in Illinois Medicaid (Medical Assistance) and related health plans.
- To standardize credentialing processes, improve transparency around recoupments, and bolster supports for providers enrolling in the Medicaid system.
Key Provisions
1) Universal credentialing and renewals (Public Aid Code – new Section 5-30.19)
- Establishes a process for universal provider credentialing using a CAQH-developed universal provider application for health care professionals and providers who seek to participate in an MCO network.
- Requires MCOs to use the CAQH universal credentialing application, and requires CAQH for renewal of credentials.
- Department of Healthcare and Family Services (DHFS) may revise the CAQH applications to align with industry or national standards.
- Within 180 days after DHFS adopts rules, health and dental plan carriers in Illinois must accept the CAQH universal credentialing application and the renewal application approved by DHFS.
- Carriers may still request information beyond the universal application if needed, but may not require information outside of what the universal application or renewal requires.
2) MCO provider network consultant (new requirement)
- All MCOs must provide a provider network consultant to act as a liaison between health care providers and the MCO.
- Contact information for the provider network consultant (name, phone, email) must be provided to each enrolled provider, upon enrollment and annually thereafter.
3) Provider enrollment consultant (new DHFS-supported role)
- The Department must employ provider enrollment consultants with duties including:
- Assisting providers in enrolling in the Illinois Medicaid Program Advanced Cloud Technology (ACT) system.
- Assisting providers seeking credentials with MCOs.
- Helping navigate enrollment and credentialing, serving as a liaison between providers and MCOs.
- Promoting enrollment in the Medical Assistance program, especially in rural areas.
4) Recoupments and remittance transparency (Insurance Code – changes to 368d)
- Requires remittance advice to health care professionals/providers detailing any recoupment or offset by insurers, HMOs, IPAs, MCOs, or physician-hospital organizations.
- Remittance advice must include: patient name, date of service, service code or description, recoupment amount, and reason for recoupment/offset.
- Remittance advice or demand for recoupment must include a telephone number and/or mailing address to initiate an appeal, with the appeal deadline clearly stated (60 days from receipt of remittance advice).
- Clarifies that certain prospective or concurrent payments with retrospective reconciliation under contract are not considered a recoupment.
- Prohibits recoupments or offsets from being requested or withheld from future payments 12 months or more after the original payment, with specified exceptions:
- Formal findings of fraud or material misrepresentation by a court/government agency/tribunal/arbitrator.
- Insurer acting as plan administrator for the Comprehensive Health Insurance Plan Act.
- Provider already paid in full by another payer/third party/workers’ compensation.
- When required by Medicaid-related federal requirements (and related departmental contracts).
- Mutual agreement to a different time limit if the recoupment is requested within 12 months.
- Contracts between insurers/MCOs and providers may not include recoupment provisions that violate these rules. The section allows normal coordination of benefits (COB) without recouping beyond the 12-month limit.
5) Effective date
- The act takes effect January 1, 2027.
Who Is Affected
- Health care professionals and health care providers seeking to participate in Illinois MCO networks.
- Managed care organizations and health/dental plan carriers operating in Illinois.
- The Department of Healthcare and Family Services (DHFS) and the Illinois Insurance Code enforcement officials.
- Medicaid program enrollees indirectly benefit through potentially smoother enrollment and clearer provider-network access.
Procedural/Timeline Aspects
- DHFS must adopt implementing rules to require universal credentialing via CAQH and CAQH renewals; rules to conform to industry standards.
- Carriers must accept the CAQH universal credentialing and renewal applications within 180 days of rule adoption.
- The Act specifies effective date: January 1, 2027.
Notes
- The bill emphasizes standardization of credentialing, clearer communications regarding recoupments, and enhanced support for providers navigating enrollment in Medicaid and MCO networks.
- It preserves flexibility for carriers to request additional information beyond the universal applications while maintaining a 12-month forward-looking recoupment cap with enumerated exceptions.
Compiled from official sources — confirm details with the bill’s official record.
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