Section 140.40  Prior Approval for Medical Services or Items

a)         The Department may impose prior approval requirements as specified by rule, to determine the essentialness of medical care provided in individual situations.  Such requirements shall be based on recommendations of technical and professional staff and advisory committees.

b)         In general, in order for prior approval to be granted, items and services must be:

1)         non-experimental,

2)         appropriate to the client's needs,

3)         necessary to avoid institutional care, and

4)         medically necessary to preserve health, alleviate sickness, or correct a handicapping condition.

c)         Providers are responsible for requesting prior approval for medical services or items.  Prior approval requests must include at a minimum:

1)         patient name,

2)         recipient number,

3)         patient age, address, and whether or not the patient resides in a group care facility,

4)         identification of the practitioner prescribing or ordering the item or service,

5)         diagnosis,

6)         description of item or service,

7)         treatment plan,

8)         how long the service or item will be needed, and

9)         purchase or rental cost.

d)         To the extent possible, the request should show how the item or service is expected to correct or help the condition, and why the requested treatment plan is better than any other plan commonly used to deal with similar diagnoses or conditions.  Anything unique to the medical condition or living arrangement affecting the choice of a recommended treatment plan or item should be explained.

e)         A written notice of disposition of the request for prior approval will be sent to the client within the time limits prescribed below.  If the notice of disposition is not sent within the applicable time limit, prior approval will be granted automatically.  Oral notification will be given only when a request for medical transportation is approved.

(Source:  Amended at 22 Ill. Reg. 19898, effective October 30, 1998)