Section 140.473  Prior Approval for Home Health Care Services

a)         Prior approval is required for the provision of home health services described in Section 140.472.  The decision to approve or deny a request for prior approval will be made within 21 days after the date the request is received or within 21 days after receipt of additional information, whichever occurs later.  Prior approval is also required for participants needing more than one skilled nursing visit per day.

b)         Prior approval is required for the provision of all home health services to terminally ill participants covered under the Transitional Assistance Program and the Family and Children Assistance Program.

c)         Effective July 1, 2012, prior approval is not required for intermittent skilled nursing services provided by a home health agency provider for participants within the first 60 days after discharge from an acute care or rehabilitation hospital when services are initiated within 14 days after discharge.

d)         Prior approval is required for all in-home shift nursing for individuals who are under 21 years of age or who receive services under the Illinois Home and Community-Based Services Waiver for Persons who are Medically Fragile, Technology Dependent (MFTD Waiver).  The decision to approve or deny a request for prior approval will be made within 21 days after the date the request is received or within 21 days after receipt of additional information, whichever occurs later.  Review of services for individuals eligible for in-home shift nursing under the MFTD Waiver will be made in accordance with 89 Ill. Adm. Code 120.530.

e)         Approval will be granted when, in the judgment of a consulting physician and subject to the review of the professional staff of the Department, the services are medically necessary and appropriate to meet the participant's medical needs.

f)         Medical equipment and supplies are subject to the prior approval requirements outlined in Sections 140.40 and 140.478. Documentation of the face-to-face encounter described in Section 140.475(g) must be submitted with the prior approval.

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)