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Reporting Critical Incidents & Fraud

ABUSE, NEGLECT, AND EXPLOITATION

If you or one of your staff member’s witness, are informed of, or suspect an incident of abuse, neglect, or exploitation, you are mandated by CMS and the Illinois Department of Healthcare and Family Services (HFS) to report the allegation immediately.


Ways to Report Critical Incidents

  • IlliniCare Health Provider Services: 866-329-4701 
  • Office of Inspector General: 800-368-1463
  • Adult Protective Services: 866-800-1409 
  • Child Abuse Hotline: 800-252-2873
  • Skilled Living Facility Complaint Hotline: 800-226-0768
  • Nursing Facility Complaint Hotline: 800-252-4343

  • Neglect. When an individual fails to provide or withhold the necessities of life, including, but not limited to, food, clothing, shelter, or medical care.
  • Abuse. Causing any physical, sexual or mental injury to an individual, including exploitation of the individual’s financial resources.
  • Bodily harm. Any injury, damage or impairment to an individual’s physical condition, or making physical contact of an insulting or provoking nature with an individual.
  • Mental abuse. The use of demeaning, intimidating or threatening words, signs, gestures or other actions about an individual or individuals that results in emotional distress or maladaptive behavior, or could have resulted in emotional distress or maladaptive behavior, for any individual present.
  • Physical abuse. Non-accidental and inappropriate contact with an individual that causes bodily harm.
  • Sexual abuse. Any sexual behavior, sexual contact or intimate physical contact,including coercion or encouragement of an individual to engage in sexual activity that results in sexual contact, intimate physical contact, sexual behavior or intimate physical behavior.
  • Financial Exploitation. Using an individuals financial resources without consent. This includes improper use of guardianship or power of attorney.

Critical Incident Reporting Guidelines

Referral Entity When to Refer
Adult Protective Services To report suspected abuse, neglect, or financial exploitation of a member age 60 or older or a member with disabilities age 18-59.
Office of the Inspector General To report suspected abuse, neglect, financial exploitation or death of members with a disability who reside in or receive mental health/developmental disability services from DHS-operated or DHS-funded agencies.
Illinois Department of Public Health - NF Complaint Hotline To report suspected abuse, neglect, or financial exploitation of members living in nursing facilities (NF).
HFS - SLF Complaint Hotline To report suspected abuse, neglect, or financial exploitation of members living in skilled living facilities (SLF).
Child Abuse Hotline If you suspect that a child has been harmed or is at risk of being harmed by abuse or neglect.

Reporting Fraud

Fraud means knowing and willful deception, or a reckless disregard of the facts, with the intent to receive an unauthorized benefit. Examples of fraud include upcoding and billing for services that were not performed. All information will be kept private.


Ways to Report Fraud

  • IlliniCare Health Provider Services: 866-329-4701 
  • IlliniCare Health Fraud/Abuse Hotline: 866-685-8664 
  • Medicaid/Welfare Fraud Hotline: 844-ILFRAUD (844-453-7283)
  • Medicare Fraud Hotline: 800-MEDICARE (800-633-4227)