Critical incidents regarding member health, safety and welfare are defined by Illinois State law. They involve actions that may jeopardize the health, safety, and well-being of vulnerable adults by causing harm or creating a serious risk of harm to a person by their caregiver or other trusted individual, whether or not harm is intentional.
Critical Incidents & Reporting
CountyCare takes member health, safety and welfare very seriously, and has a reporting process that complies with Illinois and federal laws.
Types of Critical Incidents include:
- Physical abuse – the willful infliction of physical pain or injury, or the willful deprivation of services necessary to the physical safety of an individual
- Psychological abuse – an act that inflicts emotional harm, invokes fear or humiliation or otherwise negatively impacts the mental health or safety of an individual
- Neglect – the failure of an agency, facility, employee, or caregiver to provide essential services necessary to maintain the physical and or mental health of a vulnerable adult
- Financial exploitation – the misuse or taking of the vulnerable adult’s property or resource using undue influence, breach of a fiduciary relationship, deception, harassment, criminal coercion, theft, or other unlawful or improper means
Critical Incident Reporting Requirements
Incidents involving member abuse, neglect and financial exploitation must be reported to the appropriate authorities, as mandated by state law.
How to Report a Critical Incident
Critical incidents related to CountyCare members can be reported to CountyCare by fax, email, or phone.
- Fax a completed Critical Incident Reporting Form to 312-637-8312
- Email a completed Critical Incident Reporting Form to email@example.com
- Call Provider Services at 312-864-8200 / 855-444-1661 / 711 TTD/TTY
You may also report a critical incident to the appropriate state agency, as follows:
- For members age 18 and older – Contact the Illinois Department on Aging, Adult Protective Services Hotline at 866-800-1409.
- For members in nursing facilities – Contact the Illinois Department of Public Health, Nursing Home Complaint Hotline at 800-252-4343 24 hours a day.
Program Integrity (Fraud, Waste, Abuse, Mismanagement and Misconduct)
CountyCare takes the detection, investigation, and prosecution of fraud, waste, abuse, mismanagement and misconduct very seriously. CountyCare’s Program Integrity efforts operate under policies, procedures and guidelines to ensure compliance with all Illinois and federal laws and regulations.
CountyCare’s Program Integrity efforts include performing front and back end audits to ensure provider compliance with billing regulations.
A Special Investigation Unit (SIU) performs routine internal monitoring and back end auditing of program integrity compliance risks and investigations of any issues identified. CountyCare promptly responds to compliance issues detected, including the correction of issues through education and the implementation of corrective action plans in compliance with program integrity-related requirements. In some cases, this may result in taking the appropriate actions against those who, individually or as a practice, commit fraud, waste, abuse, mismanagement or misconduct , including but not limited to:
- Remedial education and/or training to attempt to eliminate the egregious action
- Increasingly stringent utilization review process
- Recoupment of previously paid monies from a provider/practice
- Termination of provider agreement or other contractual arrangements
- Civil and/or criminal prosecution
- Any other remedies available to rectify the issue identified
The CountyCare SIU may also conduct prepayment reviews of provider claims as a result of suspected fraud, waste, abuse, mismanagement or misconduct, which may require the provider to submit additional records or documentation.
Some of the most common fraud, waste, abuse, mismanagement or misconduct issues identified are:
- Unbundling of codes
- Add-on codes without primary CPT
- Diagnosis and/or procedure code not consistent with the member’s age/gender
- Use of exclusion codes
- Excessive use of units
- Misuse of benefits
- Claims for services not rendered
- Claims for services not covered
If you suspect or witness a provider inappropriately billing for Medicaid services or a member receiving inappropriate services, please call our anonymous and confidential hotline at 844-509-4669.
For more information on CountyCare’s Program Integrity process and efforts, please see the Provider Manual.
For more information on the False Claims Act and other federal and state laws including administrative, civil and criminal remedies for false claims and statements, and whistleblower protections with respect to the role of such laws in preventing and detecting fraud, waste, abuse, mismanagement, and misconduct in federal health care programs, please see the Cook County Health FWA Policy.
CountyCare expects that its providers will cooperate with all appropriate federal and state agencies in the detection and prevention of fraud, waste, abuse mismanagement and misconduct, as well as all investigations or prosecution by any duly authorized agency.
Provider Complaints, Disputes, Member Grievances, and Member Appeals
CountyCare has established a system to allow members and providers to bring their concerns to our attention. See below for additional information on provider complaints, member grievances and member appeals.
CountyCare has established a provider complaint system that allows a provider to dispute the policies, procedures, or any aspect of the administrative function. We take all complaints very seriously, and all provider complaints will be thoroughly investigated. CountyCare has designated a Provider Complaints Coordinator (PCC) to process these provider complaints. The PCC will provide written notice of resolution to the provider within thirty days from the decision date.
Provider Complaints may be submitted in writing to:
CountyCare Health Plan
P.O. Box 21153
Eagan, MN 55121
Or you can call Provider Services at 312-864-8200 / 855-444-1661 (toll-free) / 711 (TTD/TTY).
Providers have the right to submit a dispute to decisions made by CountyCare. Providers may submit a dispute through the CountyCare Provider Dispute System. Provider disputes may be submitted for any of the following reasons: payment/claims, contracting, eligibility, prior authorization, provider enrollment, or system issue. All requests for disputes must be received within 60 calendar days from the date of the Explanation of Payment (EOP) or Remittance Notice. Once all necessary information has been received from the provider, all dispute types will be researched and responded to in no more than 30 business days from receipt of the dispute, with either a completed resolution OR a substantive response detailing the actions and timeframe to resolve the dispute. Note that Member Services and Provider Relations representatives will not be able to create tickets on behalf of providers.
The Provider Dispute System User Guide is available for instructions on how to access, register, and submit a Provider Dispute.
A member grievance is a complaint about any matter impacting a member other than a denied, reduced, or terminated service or item. The grievance process allows the member or the member’s appointed representative (guardian, caretaker, relative, PCP or other treating physician) acting on behalf of the member, to file a grievance either verbally or in writing. CountyCare will acknowledge the receipt of a grievance within forty-eight (48) hours and will attempt to resolve all grievances as soon as possible, but no later than ninety (90) days from the receipt of the grievance.
CountyCare values its providers and will not take adverse action against providers who file a grievance on a member’s behalf.
For additional information on how to file a grievance on behalf of a member, please see the Provider Manual.
An appeal is a request to review a denial or limited authorization of a requested service for a member. The appeals process allows the member or the member’s appointed representative (guardian, caretaker, relative, PCP or other treating physician) to act on behalf of the member to file an appeal either verbally or in writing within sixty (60) days following the date of the decision (or Adverse Benefit Determination) that generates the appeal.
All appeals must be registered initially with CountyCare and appealed to the Department of Healthcare and Family Services when CountyCare’s process has been exhausted. CountyCare values its providers and will not take adverse action against providers who file an appeal on a member’s behalf.
For additional information on how to file an appeal on behalf of a member, please see the Provider Manual.
HCBS Waiver Providers –
Communication with Care Coordination
Communication and collaboration between HCBS Waiver Providers and Care Coordination is essential to ensuring the health, safety, and welfare of CountyCare’s HCBS members.
Please utilize the HCBS Member Communication Form to communicate member needs, changes, and issues to ensure they are addressed timely, including:
- Start Date of Services
- When services need to be placed on hold, with the date and reason
- When services are resumed
- Changes in Member’s Living Situation (provide new address/phone if applicable)
- Changes in Member’s Condition and/or Circumstances
- Member’s Refusal or Non-Cooperation with Services