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 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.

(Source:  Amended at 45 Ill. Reg. 5848, effective April 20, 2021)