Provider Notice issued 09/19/2023

This notice informs hospitals of an add-on payment to psychiatric inpatient claims for certain long-acting injectable (LAI) antipsychotic drugs, effective with dates of service beginning January 1, 2022. The add-on is applicable to both Medicaid fee-for-service (FFS) and HealthChoice Illinois managed care organization (MCO) claims.

Per Public Act 102-0043 and 89 Ill. Admin. Code section 148.110, the Medical Assistance Program will separately reimburse hospitals at the Practitioner Fee Schedule rate (Unit Price multiplied by the units billed) for the following LAI antipsychotic drugs administered in the hospital inpatient setting for a mental health disorder. This reimbursement is a separate add-on to the psychiatric inpatient per diem rate. Please note, the Public Act also allows an add-on payment for any LAI substance use disorder drug. That programming is still in process and hospitals will be notified at its completion.

The following criteria as identified in 89 Ill. Admin. Code section 148.110 must be adhered to regardless of whether the customer is enrolled in FFS or an MCO:

· The prescriber must be a board-certified psychiatrist or a board-eligible psychiatrist. For the purposes of this subsection, a "board-eligible psychiatrist" is a physician who has, within the past 7 years, successfully completed residency training accredited by theAccreditation Council for Graduate Medical Education or approved by the American Board of Psychiatry and Neurology in a psychiatric primary specialty or subspecialty.

• The LAI atypical antipsychotic drug prior approval will follow the Food and Drug Administration (FDA) approved labeling for the indication for each medication.

• The prescriber agrees to coordinate a follow up outpatient appointment for administration of the next recommended dose of the LAI atypical antipsychotic agents and provide documentation of the follow up appointment with request for prior approval.

Payment for the add-on is contingent upon the prior approval process outlined below:

Prior Approval Process

For individuals enrolled in a HealthChoice MCO, providers must follow the prior approval process established by the MCO.

For the Medicaid fee-for-service program, either the prescriber or the hospital may submit a prior approval request. Prior approval must be requested before administration using the process detailed below. The Department’s clinical review staff will make a decision based upon the information provided on the request, medical necessity, appropriateness, and anticipated customer benefits. It is of utmost importance that prior approval requests contain adequate information upon which to make an informed decision. If the provider is prescribing a non-preferred LAI, the provider will need to provide clinical justification supporting the customer’s need for the requested drug instead of an alternative that is preferred.

A retroactive approval may be requested for dates beginning January 1, 2022, until the date of this notice. These retroactive approval requests must be received by the Department within 90 days of the date of this notice. Beginning with the date of this notice, hospitals must request approval prior to the service date or post-approval in accordance with 89 Ill. Admin. Code section 140.43.

Methods of Requesting Prior Approval

Regardless of the medium through which the prior approval request is transmitted, the provider should provide all information requested on the Form HFS 1409X , Request for Drug Prior Approval. In particular, providers should ensure that the place of infusion/injection (Section G on the 1409X) and an attestation that follow-up care requirements have been met (Section K on the 1409X) are completed.

·Drug Prior Approval Hotline: 1-800-252-8942

·Fax:     1-217-524-7264

·Mail:    Illinois Department of Healthcare and Family Services

Pharmacy Prior Approval Unit
607 E Adams, 4th Floor
Springfield, IL 62701

Questions regarding this notice may be directed to a hospital billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or to the applicable MCO.

Kelly Cunningham, Administrator
Division of Medical Programs