89 Ill. Adm. Code 140.40
Prior Approval for Medical Services or Items
Section 140
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.