Provider Notice issued 04/01/16

Prior Approval for Non-Emergency Specialty Care Transportation

To: Enrolled Ambulance Providers
Date: March 31, 2016
Re: Prior Approval for Non-Emergency Specialty Care Transportation

The purpose of this notice is to inform ambulance providers of prior approval requirements and criteria for reimbursement by the Department for non-emergency Specialty Care Transportation (SCT).

Effective May 1, 2016, prior approval will be required for non-emergency SCT in accordance with guidelines set forth in Section T-211, Prior Approval for Non-Emergency Transportation, of the Handbook for Providers of Transportation Services (pdf). 

To request prior approval for SCT, a Single Trip Form and supporting documentation must be faxed to First Transit at 630-873-1450.  Prior approval cannot be requested through the NETSPAP portal.  The following components are required and must be documented in writing for prior authorization consideration:

1. Patient’s condition exceeds ALS2 level of care. 
2. Transport is inter-facility; meaning between “facility” as defined at 42 CFR Ch. IV, § 483.5 and hospital.
3. Care is beyond that of an EMT-Paramedic in accordance with 77 Ill. Adm. Code 515-860.
4. Patient’s medical needs meet one of the following condition codes:
   1. Advanced airway management, such as a ventilator, apnea monitor, possible intubation needed, deep suctioning; or
   2. Administration or monitoring of I-V medications during transport.
5.  CTS Form, an MCA form and the run report are included.

Due to system limitations, First Transit was unable to issue prior approvals for SCT. The base rate did not require a prior approval and was reimbursed. However, the miles and oxygen rejected for no prior approval. 
First Transit can now issue post approvals for SCT with dates of service within 20 business days of the transport.  Providers who need to be paid for services beyond the 20 business days must request a post approval by contacting an HFS billing consultant by phone for further instruction. 

The billing consultants can be reached at 1-877-782-5565, option 3, option 3. To be considered for post approval for claims affected by this system limitation, requests must be submitted to an HFS billing consultant within 60 days of this notice.

Providers have 180 days from the post approval date to bill HFS.  Providers must request a timely filing override for claims with dates of service over 180 days.  Additional timely filing information can be found on the HFS website.     

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565, option 3, option 3.

Felicia F. Norwood
Director