Ill. Admin. Code tit. 89, § 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.
Notes
Amended at 22 Ill. Reg. 19898, effective October 30, 1998
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