Current through Register Vol. 48, No. 38, September 20, 2024
a) For payment to
be made, the transportation service must be to the nearest available
appropriate provider, by the least expensive mode that is adequate to meet the
individual's need. When public transportation is available and is a practical
form of transportation, payment will not be made for a more expensive mode of
transportation.
b) Approval from
the Department, or its authorized agent, is required prior to providing
transportation to and from the source of medical care, except:
1) For transportation provided by an
ambulance in emergency situations.
2) For transportation provided by an
ambulance for an individual who is transported from one hospital to a second
hospital for services not available at the sending hospital.
3) For transportation provided by a
helicopter when it is demonstrated to be medically necessary as indicated by
the written order of the responsible physician in an emergency situation. An
emergency may include, but is not limited to:
A) life threatening medical
conditions;
B) severe burns
requiring treatment in a burn center;
C) multiple trauma;
D) cardiogenic shock; and
E) high-risk neonates.
4) When post-authorization, informal review
of request for appeal, and appeal are allowed.
c) Requirements, for Dates of Service
Beginning February 1, 2019, for Medi-Car, Service Car, and Non-emergency
Ambulance Services and for Medical Certifications and Orders
1) Whenever a patient covered by a medical
assistance program under this Part, or by another medical program administered
by the Department, is being transported from a facility, a physician, or, in
the case of a Long Term Care Facility, the Medical Director, or another medical
professional acting within his or her scope of practice and in accordance with
the privileges granted by the medical staff, who is responsible for the
diagnosis and treatment of the patient, shall complete a written and signed
Physician Certification Statement for each patient whose transportation
requires medi-car, service car or medically supervised ground ambulance
services. The Physician Certification Statement shall specify the type and
level of transportation needed. A medical professional includes:
A) Licensed Physician Assistant
(PA)
B) Licensed Nurse Practitioner
(NP)
C) Licensed Clinical Nurse
Specialist (CNS)
D) Licensed
Registered Nurse (RN)
E) Discharge
Planner
F) Licensed Practical Nurse
(LPN)
G) Licensed Clinical Social
Worker (LCSW)
2) A
Physician Certification Statement establishing that the patient's condition
meets the Department's criteria for approval of medi-car or service car as set
forth in Section
140.490 or
non-emergency ambulance service, as set forth in Table A, must be completed by
a physician, or, in the case of a Long Term Care Facility, the Medical
Director, or a medical professional acting within his or her scope of practice
and in accordance with the privileges granted by the medical staff, who is
responsible for the diagnosis and treatment of the patient. Should the
Physician Certification Statement, published by the Department, serve as the
discharge order, it must be signed or authenticated, as allowed under Illinois
law, by a physician, or, in the case of a Long Term Care Facility, the Medical
Director, or a medical professional acting within his or her scope of practice
and in accordance with the privileges granted by the medical staff.
3) Each physician, or, in the case of a Long
Term Care Facility, the Medical Director, or a medical professional acting
within his or her scope of practice and in accordance with the privileges
granted by the medical staff, may designate another licensed healthcare
provider or discharge planner, not employed by a transportation provider, to
complete the Physician Certification Statement. The physician, or, in the case
of a Long Term Care Facility, the Medical Director, or a medical professional
acting within his or her scope of practice and in accordance with the
privileges granted by the medical staff, remains responsible for the accuracy
and authentication of the Physician Certification Statement, and any
determination that the patient's condition meets the requirements for the
Department's criteria for medi-car or service car as set forth in Section
140.490 or
non-emergency ambulance transports, as set forth in Table A.
4) Facilities shall develop procedures to
secure the completion of the Physician Certification Statement prior to the
patient's transport from the facility and prior to the non-emergency ambulance
service. However, the facility shall provide the Physician Certification
Statement to the transportation provider no later than 10 calendar days after
the transportation provider requests it. The transportation provider shall have
90 calendar days from the date of the transport to submit the Physician
Certification Statement or the attempt to obtain the Physician Certification
Statement (see subsection (c)(5)) to the Department or its agent.
5) If the ground ambulance provider, medi-car
provider, or service car provider is unable to obtain the required Physician
Certification Statement within 10 calendar days following the date of the
service, the provider must document its attempt to obtain the requested
certification and may then submit the claim for payment. Acceptable
documentation includes a signed return receipt from the U.S. Postal Service,
facsimile receipt, email receipt, or other similar service that evidences that
the provider attempted to obtain the required PCS from the patient's attending
physician or other medical professional listed in subsection (c)(1).
6) Failure by a facility to complete a
Physician Certification Statement prior to a non-emergency ambulance service
shall not prevent an ambulance provider as described in Section
140.490(a)(1)
from filing an appeal of an informal review conducted by the Department or its
authorized agent pursuant to 89 Ill. Adm. Code
104.205(d).
d) To be eligible for non-emergency ambulance
transportation, the services must meet the criteria set forth in Table A. The
Department or its agent may require documentation to prove that the services
meet the criteria set forth in Table A.
e) An on-going prior approval, with duration
of up to six months, may be obtained when subsequent trips to the same medical
source are required. When prior approval is sought for subsequent trips to the
same medical service, the client's physician or other medical professional must
supply the Department, or its authorized agent, with a Physician Certification
Statement describing the nature of the medical need, the necessity for on-going
visits, already established appointment dates and the number and expected
duration of the required on-going visits.
f) The Department shall refuse to accept
requests for non-emergency transportation authorizations, including prior
approval and post-approval requests, and shall terminate prior approvals for
future dates, for a specific non-emergency transportation vendor, if:
1) the Department has initiated a notice of
termination of the vendor from participation in the Medical Assistance
Program;
2) the Department has
issued a notification of its withholding of payments due to reliable evidence
of fraud or willful misrepresentation pending investigation; or
3) the Department has issued notification of
its withholding of payments based upon any of the following individuals having
been indicted or otherwise charged under a law of the United States or Illinois
or any other state with a felony offense that is based upon alleged fraud or
willful misrepresentation on the part of the individual related to:
A) the Medical Assistance Program;
B) a Medical Assistance Program provided in
another state that is of the kind provided in Illinois;
C) the Medicare program under Title XVIII of
the Social Security Act; or
D) the
provision of health care services:
i) if the
vendor is a corporation, an officer of the corporation or an individual who
owns, either directly or indirectly, five percent or more of the shares of
stock or other evidence of ownership of the corporation; or
ii) if the vendor is a sole proprietorship,
the owner of the sole proprietorship; or
iii) if the vendor is a partnership, a
partner of the partnership; or
iv)
if the vendor is any other business entity authorized by law to transact
business in the state, an officer of the entity or an individual who owns,
either directly or indirectly, five percent or more of the evidences of
ownership of the entity.
g) If it is not possible to obtain
prior-approval for non-emergency transportation, post-approval must be
requested from the Department or its authorized agent.
h) Post-approval may be requested for items
or services provided during Department working and non-working hours or working
and non-working hours of its agents, whichever is applicable, or when a life
threatening condition exists and there is not time to call for
approval.
i) To be eligible for
post-approval consideration, the requirements for prior-approval must be met
and post-approval requests must be received by the Department or its agents,
whichever is applicable, no later than 30 calendar days after the date services
are provided. A request for payment submitted to a third party payor will not
affect the submission time frames for any post-approval request. Exceptions to
the aforementioned post-approval request time frames will be permitted only in
the following circumstances:
1) The Department
or the Department of Human Services has received the patient's Medical
Assistance Application, but approval of the application has not been issued as
of the date of service. In such a case, the post-approval request must be
received no later than 90 calendar days after the date of the Department's
Notice of Decision approving the patient's application.
2) The patient did not inform the provider of
his or her eligibility for Medical Assistance. In such a case, the
post-approval request must be received no later than six months after the date
of service, but will be considered for payment only if there is attached to the
request a copy of the provider's dated private pay bill or collection response,
which was addressed and mailed to the patient each month after the date of
service.
j) An ambulance
provider as described in Section
140.490(a)(1)
may appeal any decision by the Department or its authorized approval agent for
which:
1) No denial or approval was received
prior to the time of the non-emergency transport.
2) An approval decision entitles the
ambulance service provider to a lower level of compensation from the Department
than the ambulance service provider would have received as compensation for the
level of service requested.
3) The
ambulance service provider shall have 90 calendar days from the date of service
to file a request for informal review of the request for appeal in accordance
with 89 Ill. Adm. Code 104.205. The decision date and appeal deadline will
appear on notices generated by the Department or its prior approval
agent.
