Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.31 - Emergency Services Audits

Current through Register Vol. 48, No. 28, July 12, 2024
a) All
				emergency services for which charges are made to the Department and are
				provided to a recipient who does not require admission as an inpatient are
				subject to audit.
b) An emergency
				services audit shall be limited to a review of records related to services
				rendered within three years of the date the hospital is notified that the audit
				will be initiated. The Department shall notify the hospital of an audit at
				least four calendar weeks before the audit occurs, unless the hospital and the
				Department agree to schedule the audit at an earlier date. The hospital's
				business and professional records for at least 12 previous calendar months
				shall be maintained and available for inspection by authorized Department
				personnel on the premises of the hospital. Department personnel shall make
				requests in writing to inspect records more than 12 months old at least two
				business days in advance of the date they must be produced. These records
				required to be maintained shall be kept in accordance with accepted business
				and accounting practice and shall be legible. Such records must be retained for
				a period of not less than three years from the date of service or as provided
				by applicable State law, whichever period is longer, except that if an audit is
				initiated within the required retention period the records must be retained
				until the audit is completed and every exception resolved by settlement or by
				the Director's final decision.
c)
				All records required to be maintained shall be available for inspection by
				authorized Department personnel during normal business hours. Department
				personnel shall make all attempts to examine such records without interfering
				with the professional activities of the hospital. The hospital shall make
				legible copies of those records requested by the Department upon completion of
				its inspection, and tender said copied records to the Department within two
				weeks after such request is made unless this time is extended by mutual
				consent. Additionally, if the hospital locates records that were unavailable
				during the audit, that data shall be submitted to the Department within 30 days
				after completion of the audit conducted on the hospital's premises, and that
				data shall be utilized in generating the audit findings. The determination that
				an emergency medical condition exists shall be based solely upon the review of
				the legible information contained in those medical records supplied by the
				hospital during the audit.
d)
				Authorized Department personnel shall meet with the chief executive officer of
				the hospital, or a person designated by the chief executive officer, upon
				arrival at the hospital to conduct the audit and at the conclusion of the
				audit. The purpose of the pre-audit meeting shall be to inform the hospital of
				the scope of the audit. The purpose of the post-audit meeting shall be to
				provide an opportunity for the auditors to discuss their preliminary findings
				with the chief executive officer, or a person designated by the chief executive
				officer. More detailed audit findings shall be provided in writing to the
				hospital within 120 days after the date on which the audit conducted on the
				hospital premises was completed.
e)
				The final determination of whether an emergency room visit was for the
				alleviation of severe pain or for the immediate diagnosis and/or treatment of
				conditions or injuries which might result in disability or death if there is
				not immediate treatment shall be based upon the symptoms and condition of the
				recipient at the time the recipient is initially examined by the hospital's
				emergency department physician and not upon the final determination of the
				recipient's actual medical condition (see Sections
				140.3
				and
				140.5
				of this Part).
f) When the purpose
				of the audit is to determine the appropriateness of the emergency services
				provided, any final determination that would result in a denial of or reduction
				in payment to the hospital shall be based on the opinion of a physician
				licensed to practice medicine in all of its branches who is board certified in
				emergency medicine or by the appropriate health care professionals under the
				supervision of the physician.
g)
				The Department or its designated review agent in cases where the Department
				seeks to recover an extrapolated amount, shall use statistically valid sampling
				techniques when conducting audits as provided by Section
				140.30
				of this Part.
h) This Section shall
				not apply to any audits initiated prior to July 1, 1992.