TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.491 MEDICAL TRANSPORTATION LIMITATIONS AND AUTHORIZATION PROCESS


 

Section 140.491  Medical Transportation Limitations and Authorization Process

 

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 non-emergency ambulance services for discharging patients, medical certifications and orders, for dates of service beginning July 1, 2013.

 

1)         Whenever a patient covered by a medical assistance program under this Part, or by another medical program administered by the Department, is being discharged from a facility, a physician, or, in the case of a Long Term Care Facility, the Medical Director, or a licensed healthcare provider 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 discharge order for each patient whose discharge requires medically supervised ground ambulance services. The order shall specify the level of ground ambulance services needed.

 

2)         A medical certification establishing that the patient's condition meets the Department's criteria for approval of 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 licensed healthcare provider 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 medical certification form, 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 licensed healthcare provider 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 licensed healthcare provider 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 medical certification form. The physician, or, in the case of a Long Term Care Facility, the Medical Director, or a licensed healthcare provider acting within his or her scope of practice and in accordance with the privileges granted by the medical staff, remains responsible for the accuracy of the medical certification, authentication of the discharge order, and any determination that the patient's condition meets the requirements for the Department's criteria for non-emergency ambulance transports, as set forth in Table A. 

 

4)         Facilities shall develop procedures to facilitate the completion of the discharge order and the medical certification form prior to the patient's discharge from the facility and prior to the non-emergency ambulance service.  The ambulance service provider shall have 90 days from the date of the transport to submit the discharge order and medical certification form to the Department or its agent.

 

5)         Failure by a facility to complete a discharge order and medical certification form 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-emergent 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 provider must supply the Department, or its authorized agent, with a brief written 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; or

 

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 non-working hours or 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.

 

(Source:  Amended at 41 Ill. Reg. 999, effective January 19, 2017)