Public Notice issued 10/09/14

Removal of Caps for Adult Therapy Services

As a result of Public Act 098-0651(pdf), effective with dates of service on and after October 1, 2014, the department will no longer limit therapy services to 20 visits per year per discipline for participants age 21 and older. Prior approval of services for medical necessity will continue to be required for adults.

Prior approval of services for medical necessity for children will be required at a later date. Providers will be notified via informational notice before that requirement is implemented and should ensure they are registered for email notification of provider releases on the HFS Provider Releases and Bulletins E-mail Notification Request webpage.

Outpatient therapy providers must submit the following information for each prior approval:

• HFS 3701T (pdf), Therapy Prior Approval Request Form,
• Practitioner Order
• Therapist Plan of Care

Home health agencies must submit the following information for each prior approval:

• HFS 1409 (pdf), Prior Approval Request Form,
• Practitioner Order
• Therapist Initial Evaluation
• HCFA 485 Plan of Care

As a reminder, any renewal request should include all of the above, in addition to the therapist re-evaluation or progress report.

Initial requests and renewal requests may be faxed to 217-524-0099. Reviews and additional information may be faxed to 217-558-4359.

Prior approval to provide services does not include any determination of the patient’s eligibility. When prior approval is requested, and before the provision of each service, it is the provider’s responsibility to verify the patient’s eligibility.

Special Information Regarding Care Coordination Billing and Eligibility

The prior approval instructions in this notice apply to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs) and Care Coordination Entities (CCEs) and do not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs).

Should a participant become enrolled in an MCO or MCCN during a period of time for which a prior approval has been previously granted, the prior approval will no longer be applicable effective with the participant’s managed care enrollment date.

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. Electronic Data Interchange vendors (formerly the Recipient Eligibility Verification (REV) System), the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify any care coordination plan in which the beneficiary is enrolled. Plan contact information for questions related to coverage and billing requirements as well as information regarding the way each plan is displayed in the department’s electronic eligibility systems may be located in the June 24, 2014 informational notice titled, Revised - Care Coordination Enrollment for Children, Families and ACA Adults ;

Please Note: Prior approval requests for participants in an MCO or MCCN should be directed to the individual plan.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator
Division of Medical Programs