Provider Notice issued 10/23/15

Prior Approval for Children’s Physical and Occupational Therapy Services Effective with Dates of Service Beginning November 16, 2015

As a result of Public Act 098-0651(pdf), the Department is required to prior approve all adult and child therapy services for medical necessity. The department is now implementing prior approval for medical necessity of physical and occupational therapy for children through age 20 effective with dates of service on and after November 16, 2015. Speech therapy prior approval for children will be put into effect at a later date.
Outpatient therapy providers must submit the following information for each prior approval:

• HFS 3701T (pdf) Therapy Prior Approval Request Form
• Practitioner Order
• Therapist Initial Evaluation
• 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

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, the provider is responsible for verifying the patient’s eligibility.   

Children between the ages of 0 and 3 may be eligible to receive their physical and/or occupational therapy services through the Illinois Early Intervention Program, which provides resources and supports to children with diagnosed disabilities or developmental delays. Families should first make application to the Early Intervention Program for these services before the therapy provider submits a prior authorization request to the Department.

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 March 9, 2015 informational notice titled, Care Coordination Health Plan Identification and Billing Procedures Depending on Health Plan Enrollment (pdf). 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.

Felicia F. Norwood
Director