Provider Notice issued 08/02/12

Inpatient Utilization Review Change Mandated by P.A. 097-0689, the Save Medicaid Access and Resources Together (SMART) Act

As a result of Public Act 097-0689(pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, HFS is adding two DRG codes that will be subject to utilization review.

Hospitals are reminded that, for its medical programs, the department pays participating providers for necessary medical services. Necessary medical care is defined as care that is generally recognized as standard medical care required because of disease, disability, infirmity or impairment.

In keeping with this policy and a growing national effort to reduce preterm births resulting from elective deliveries, the recently enacted SMART Act stipulates that, effective July 1, 2012, the Department shall pay for cesarean sections at the normal vaginal delivery rate unless a cesarean section was medically necessary. The incidence of pre-term births continues to impact low-income communities within Illinois. A recognized factor is elective deliveries prior to 39 weeks gestation. HFS will be selectively reviewing billings for cesarean sections.

Effective with admissions on or after September 1, 2012, DRG 370 (Cesarean Section, W/Complications) and 371 (Cesarean Section, W/O Complications) may be subject to pre-payment utilization review by the department’s Quality Improvement Organization, eQHealth Solutions. These DRG codes will be added to Attachment D on the department’s Web site.

Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs