Illinois RAC
a service of 
- Overview
- Resources & Informational Documentation
- Dispute & Appeal Process
- Medical Record Submission
- Contact Information
Overview
Section 1902(a)(42)(B) of the Social Security Act requires that states establish a Medicaid Recovery Audit Contractor Program (RAC Program) as a mechanism to monitor the integrity of payments made to Medicaid providers. The Illinois Department of Healthcare and Family Services, Office of the Inspector General (HFS-OIG) has retained Health Management Systems, Inc. (HMS), a Gainwell Technologies company as its RAC contractor to conduct periodic reviews of claims paid by HFS-OIG for health care services rendered to Medicaid members. The objective of the RAC program is to identify and recover payments made to Medicaid providers that do not meet state and federal requirements. RAC audits, include coding validation, payment accuracy, compliance with state and federal regulations, policies, contractual requirements, and utilization standards.
This website provides information relevant to the work to be completed by HMS on behalf of HFS-OIG for the RAC Program. It is intended to support the State in achieving its mission to reduce improper Medicaid payments and to support providers with education and resources.
For state and federal statutes and regulations, refer to the following links and citations which further outline HFS-OIG’s authority and provider responsibilities with regards to service delivery, billing, and reimbursement in the Illinois Medicaid Program:
Illinois Program Rules:
- HFS-OIG Program Rules (illinois.gov)
- Illinois Administrative Code, Title 77 Public Health, Part #: 250 – Requirements for Acute Care, Limited Services and Special Hospitals
PART 250 HOSPITAL LICENSING REQUIREMENTS (ilga.gov) - Illinois Administrative Code, Title 89 – Social Services, Chapters 140 – Medicaid General Information, 140 – Medicaid General Benefit Description, 140 – Medicaid General Provider Policies, 311 – Hospital Services, 140.855 – Reconsideration of Utilization Review, 508 – Administrative Hearings, 510 – Provider Hearings (Illinois Administrative Code | Title 89 - SOCIAL SERVICES | Casetext)
Fee Schedules:
Fee for Service | Illinois Department of Healthcare and Family Services (illinois.gov)
Code of Federal Regulations:
42 CFR Part 455, Subpart F
eCFR :: 42 CFR Part 455 -- Program Integrity: Medicaid
Resources
- HMS Provider Portal
- HMS Provider Portal Training guide (PDF)
- HMS RAC Overview Presentation (Pre-recorded webinar)
Informational Documentation
Dispute Process
- Providers may request a review of findings (dispute) in writing.
- Disputes must be received within thirty (30) calendar days of the date of the Preliminary Findings Letter.
Submission Options:
Electronic (preferred method):- HMS Provider Portal
- Secure File Transfer Protocol (SFTP): For instructions to set up SFTP, please contact HMS via email at GoGreen@gainwelltechnologies.com or call 1-855-287-1682.
- HMS – Illinois Recovery Audit Services
5615 Highpoint Dr.
Mail Stop #200 - IL
Irving, TX 75038
Appeal Process
- Providers may request an appeal if they do not agree with HMS’s findings in writing or by selecting Option 3 of the “Payment Agreement or Request to Dispute Audit Findings.”
- Formal Appeal must be received within sixty (60) calendar days of the date of the Final Finding and Dispute Uphold letters.
- Appeal request must be emailed to:
- Email : HFS.OIG.BMI.RAC@illinois.gov
Medical Record Submission
Electronic Submission
- HMS prefers medical records be submitted electronically through the Provider Portal. Follow the User Registration instructions.
Mailing in Medical Records
- Providers may mail in hard copies of medical files.
- Please mail records along with a copy of the Records Request List, highlighting the corresponding claim number(s) to the address below:
HMS – Illinois Recovery Audit Services
5615 Highpoint Dr.
Mail Stop #200 – IL
Irving, TX 75038
SFTP
- Providers may also request a Secure File Transfer Protocol (SFTP) be set up for delivering electronic medical records.
- Email for SFTP submission is: GoGreen@gainwelltechnologies.com.
- Please contact HMS Provider Relations with any SFTP requests at 1-855-287-1682.
Contact Information
Provider Services is available Monday-Friday 8:00 a.m. to 4:30 p.m. Central Time at 1- 855-699-6292
Inquiry Type |
Contact Information |
| Questions About HMS Provider Portal | HMS Provider Services 1-855-699-6292 |
| Address Updates in HMS Provider Portal | HMS Provider Services 1-855-699-6292 |
| RAC Claim Status Questions | HMS Provider Services 1-855-699-6292 |
| Dispute Request | HMS 5615 Highpoint Dr. Mail Stop #200 - IL Irving, Texas 75038 |
| Appeal Request | HMS Provider Services 1-855-699-6292 |