Provider Notice issued 12/13/2023

This notice informs providers of updates to both the HFS 2270 - Physician Certification Statement (PCS) and HFS 2271 - Certificate of Transportation Services (CTS) forms. The requirement for PCS and CTS forms applies to prior approval requests and claims for customers covered under fee-for-service (FFS), as well as HealthChoice Illinois managed care organizations (MCOs) and the Medicare/Medicaid Alignment Initiative (MMAI) plans.

The forms are required for customers using non-emergency ambulance, medicar/wheelchair van, and service car transports. No PCS or CTS forms are required for private auto transports.

Reminders:

The HFS 2270 - Physician Certification Statement (PCS) form is the standardized medical necessity form for non-emergency ambulance, medicar/wheelchair van, and service car transports that certifies the appropriate level of transportation is necessary for payment and/or verification of the level of service originating from a hospital or long term care facility (LTC) and must be completed by the appropriate LTC or hospital staff, not the transportation provider.

The HFS 2271 - Certificate of Transportation Services (CTS) form is the standardized medical necessity form for non-emergency ambulance, medicar/wheelchair van and service car transports that certifies the appropriate level of transportation is necessary for payment and/or verification of the level of service originating from a customer’s home residence and must be completed by a medical professional on behalf of the customer, not the transportation provider.

PCS and CTS forms must support medical necessity for the appropriate level of transport being requested and are required for single and repetitive trips. Each form may be valid for recurring ground ambulance transports for up to 60 days, while one may be valid for recurring medi-car/wheelchair van and service car transports for up to

180 days. However, if at any time the medical necessity or the level of transportation changes, a new PCS or CTS form will be required.

A PCS or CTS form is not required prior to transport if a delay in transport can be expected to negatively affect the customer’s outcome. In these cases, the form must be provided at no charge within 10 calendar days of the request of the transportation provider. 

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS Medicaid customers, or to the applicable HealthChoice Illinois MCO or MMAI plan.

Kelly Cunningham, Administrator
Division of Medical Programs