reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart A - GENERAL PROVISIONS › Section 140.6 - Medical Services Not Covered

Current through Register Vol. 48, No. 28, July 12, 2024
The following services are not covered under the Department's
				  medical assistance programs:
a)
				Services available without charge;
b) Services prohibited by State or federal
				law;
c) Experimental
				procedures;
d) Research oriented
				procedures; other than those described in Section
				140.3(b)(27)
				and
				140.3(c)(23);
e) Medical examinations required for entrance
				into educational or vocational programs;
f) Autopsy examinations;
g) Artificial insemination;
h) Medical or surgical procedures performed
				for cosmetic purposes;
i) Medical
				or surgical transsexual treatment, for dates of service prior to April 1,
				2015;
j) Diagnostic and/or
				therapeutic procedures related to primary infertility/sterility;
k) Acupuncture;
l) Subsequent treatment for venereal disease,
				when those services are available through State and/or local health
				agencies;
m) Medical care provided
				by mail or telephone;
n) Unkept
				appointments;
o) Non-medically
				necessary items and services provided for the convenience of recipients and/or
				their families;
p) Preparation of
				routine records, forms and reports; and
q) Visits with persons other than a
				recipient, such as family members or group care facility staff.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart A - GENERAL PROVISIONS › Section 140.7 - Medical Assistance Provided to Individuals Under the Age of Eighteen Who Do Not Qualify for AFDC and Children Under Age Eight

Current through Register Vol. 48, No. 28, July 12, 2024
a) Individuals Under Age Eighteen (18)
1) Medical assistance shall be provided to
				individuals under the age of eighteen who do not qualify for AFDC under the
				definition of dependent child as defined in 89 Ill. Adm. Code
				101.20 and
				112.60
				through
				112.64.
				However, such individuals must meet the eligibility requirements and other
				provisions of 89 Ill. Adm. Code
				112.10,
				112.20,
				112. Subparts C and D,
				112.303,
				112.304 and
				112.307
				through
				112.309.
2) If non-exempt countable income is equal to
				or less than the appropriate MANG (AFDC) standard the individual is eligible
				for payment of his/her allowable medical care costs.
3) Persons whose income exceeds the
				appropriate MANG (AFDC) standard are eligible for medical assistance each month
				incurred or paid medical care costs equals the amount of excess non-exempt
				income over the standard. When income exceeds the MANG (AFDC) standard,
				eligibility begins on the day in the month incurred or paid medical care costs
				equals excess monthly income. Eligibility ends on the last day of the same
				month.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart A - GENERAL PROVISIONS › Section 140.8 - Medical Assistance For Qualified Severely Impaired Individuals

Current through Register Vol. 48, No. 28, July 12, 2024
Medical assistance shall be provided under the AABD program
				  to a qualified severly impaired individual whose Supplemental Security Income
				  (SSI) payment status is based on Section 1619 of the Social Security Act (the
				  Act) (
				  42 U.S.C.
				  1382 h )) if he/she was eligible for Medicaid
				  in the month prior to first becoming eligible under Section 1619 of the Act
				  (see 89 Ill. Adm. Code 113: Subparts B and C, and 89 Ill. Adm. Code
				  120.10 and
				  120.60
				  ). A qualified severely impaired individual is any person under age 65 who
				  received either SSI, State Supplemental Payment or special Section 1619(a) of
				  the Act benefits and was eligible for Medicaid and who the Social Security
				  Administration determines meets all of the following criteria:
a) is blind or disabled under Title XVI of
				the Act (see
				42 U.S.C.
				1382 c );
b) meets all SSI requirements except for
				earned income;
c) would be
				seriously inhibited by the lack of Medicaid coverage from continuing to work or
				obtaining employment; and
d) has
				earnings insufficient to provide a reasonable equivalent of Medicaid, SSI and
				Title XX (
				42 U.S.C.
				1397 et seq.) attendant care benefits that
				would be available if he/she did not work.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart A - GENERAL PROVISIONS › Section 140.9 - Medical Assistance for a Pregnant Woman Who Would Not Be Categorically Eligible for AFDC/AFDC-MANG if the Child Were Already Born Or Who Do Not Qualify As Mandatory Categorically Needy

Current through Register Vol. 48, No. 28, July 12, 2024
a) Pregnant Women Who Would Not Be
				Categorically Eligible for AFDC/AFDC-MANG if the Child Were Already Born
1) Medical assistance will be provided to
				applicants of any age who are pregnant and meet the asset standards of the AFDC
				medical assistance program and who would not be eligible for AFDC if the child
				were already born because:
A) the father is
				not absent, and
B) neither parent
				is incapacitated and the principal wage earner does not meet the Department's
				definition of unemployment (see 89 Ill. Adm. Code
				112.64
				).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart A - GENERAL PROVISIONS › Section 140.10 - Medical Assistance Provided to Persons Confined or Detained by the Criminal Justice System

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				Department shall pay for certain medical services provided to the following
				groups of individuals who are confined or detained in county jails or other
				detention facilities in Illinois, that are not operated by the State, and who
				are eligible for, and enrolled in, medical assistance administered under
				Article V of the Illinois Public Aid Code [305 ILCS 5 ]:
1) Individuals who, at the time of
				confinement or detention, were already enrolled for medical
				assistance.
2) Individuals who,
				subsequent to their confinement or detention, were determined eligible and
				enrolled for medical assistance.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.11 - Enrollment Conditions for Medical Providers

Current through Register Vol. 48, No. 28, July 12, 2024
a) In order to enroll for participation,
				providers shall:
1) Hold a valid, appropriate
				license where State law requires licensure of medical practitioners, agencies,
				institutions and other medical vendors.
2) Be certified for participation in the
				Title XVIII Medicare program where federal or State rules and regulations
				require such certification for Title XIX participation.
3) Be certified for Title XIX when federal or
				State rules and regulations so require.
4) Provide enrollment information to the
				Department in the prescribed format, and notify the Department, in writing,
				immediately whenever there is a change in any such information which the
				provider has previously submitted.
5) Provide disclosure, as requested by the
				Department, of all financial, beneficial, ownership, equity, surety, or other
				interests in any and all firms, corporations, partnerships, associations,
				business, enterprises, joint ventures, agencies, institutions or other legal
				entities providing any form of health care services to public aid
				recipients.
6) Have a written
				provider agreement on file with the Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.12 - Participation Requirements for Medical Providers

Current through Register Vol. 48, No. 28, July 12, 2024
The provider shall agree to:
a) Verify eligibility of recipients prior to
				providing each service;
b) Allow
				recipients the choice of accepting or rejecting medical or surgical care or
				treatment;
c) Provide supplies and
				services in full compliance with all applicable provisions of State and federal
				laws and regulations pertaining to nondiscrimination and equal employment
				opportunity including but not limited to:
1)
				Full compliance with Title VI of the Civil Rights Act of 1964, which prohibits
				discrimination on the basis of race, color or national origin;
2) Full compliance with Section 504 of the
				Rehabilitation Act of 1973 and 45 CFR 84, which prohibit discrimination on the
				basis of handicap; and
3) Without
				discrimination on the basis of religious belief, political affiliation, sex,
				age or disability;
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.14 - Denial of Application to Participate in the Medical Assistance Program

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department
				may deny an application to participate in the Medical Assistance Program if the
				vendor has engaged in activities which constitute grounds for termination,
				suspension or exclusion under Section
				140.16.
				If the activities were engaged in prior to December 1, 1977, they may be used
				as the basis for denial of an application only if the vendor had actual or
				constructive knowledge of the requirements which applied to his conduct or
				activities.
b) Denial of
				Application
1) The Department may deny an
				application submitted by a vendor if:
A) the
				vendor cannot reasonably be expected to meet the written requirements of the
				Department including those set forth in the Medical Assistance Program
				Handbooks and the Department's manuals, bulletins and releases; or
B) the Department determines, after reviewing
				the activities that served as the basis for the earlier termination or barring,
				that the application should not be approved. Factors to be considered by the
				Department in making this determination shall include:
i) length of time the vendor has not
				participated in the Medical Assistance Program;
ii) magnitude and severity of the activities
				that led to the binding administrative decision which served as the basis for
				the vendor's termination, barring or denied participation;
iii) mitigating circumstances presented by
				the vendor;
iv) whether the
				deficiencies that served as the basis for the vendor to be terminated, barred
				or denied participation are corrected;
v) whether the vendor demonstrates a fitness
				to participate in the Medical Assistance Program; and
vi) the extent to which any legally
				enforceable debts owed to the Department by the applicant or an entity in which
				the applicant or his or her nominee held a substantial ownership interest have
				been paid.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.15 - Suspension and Denial of Payment, Recovery of Money and Penalties

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective July
				1, 2012, theDepartment may suspend or deny payment, in whole or in part, to a
				vendor or the vendor's alternate payee if the payment would be improper or
				erroneous or would otherwise result in overpayment. The Department may recover
				money improperly or erroneously paid, or overpayments (see subsection (b) of
				this Section for exception to recovery of money), made to a vendor or vendor's
				alternate payee, either by setoff (deducting from Department obligations to the
				vendor or the designated alternate payee), deductions from future billings or
				by requiring direct repayment. Payments may be suspended, denied or recovered
				from a vendor or alternate payee:
1) for
				services rendered in violation of the Department's provider notices, statutes,
				rules and regulations;
2) for
				services rendered in violation of the terms and conditions prescribed by the
				Department in its vendor agreement;
3) for any vendor who fails to grant the
				Office of Inspector General of the Department timely access to full and
				complete records, including, but not limited to, records relating to recipients
				under the Medical Assistance Program for the most recent six years, in
				accordance with Section
				140.28,
				and other information for the purpose of audits, investigations or other
				program integrity functions, after reasonable written request by the Inspector
				General; provided, however, that this subsection (a)(3) does not require
				vendors to make available the medical records of patients for whom services are
				not reimbursed under this Part or to provide access to medical records more
				than six years old;
4) when the
				vendor has knowingly made, or caused to be made, any false statement or
				representation of a material fact in connection with the administration of the
				Medical Assistance Program;
5) when
				the vendor previously rendered services while terminated, suspended or excluded
				from participation in the Medical Assistance Program or while terminated or
				excluded from participation in another state or federal medical assistance or
				health care program; or
6) for
				ground ambulance services rendered as the result of improper or false
				certification. Overpayments can be recovered from a vendor, including, but not
				limited to, from the discharging physician, the discharging facility, and the
				ground ambulance service provider.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.17 - Suspension of a Vendor's Eligibility to Participate in the Medical Assistance Program

Current through Register Vol. 48, No. 28, July 12, 2024
In actions based on Section
				  140.16
				  in which the Notice states an intent to terminate, the final administrative
				  decision may result in suspension for a specific time, which shall not exceed
				  one year from the time of the final administrative decision, rather than
				  termination, when the Department determines that:
a) the seriousness and extent of the
				violations do not warrant termination; and
b) the vendor had no prior history of
				violations of the Medical Assistance Program; and
c) the lesser sanction of suspension will be
				sufficient to remedy the problem created by the vendor's violations.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.18 - Effect of Termination, Suspension, Exclusion or Revocation on Persons Associated with Vendor

Current through Register Vol. 48, No. 28, July 12, 2024
a) Upon
				termination, suspension or exclusion of a vendor of goods or services from
				participation in the Medical Assistance Program, a person with management
				responsibility for such vendor during the time of any conduct that served as
				the basis for that vendor's termination, suspension or exclusion is barred from
				participation in the Medical Assistance Program.
b) Upon termination, suspension or exclusion
				of a corporate vendor, the officers and persons owning, directly or indirectly,
				5% or more of the shares of stock or other evidences of ownership in the vendor
				during the time of any conduct that served as the basis for that vendor's
				termination, suspension or exclusion are barred from participation in the
				Medical Assistance Program.
c) Upon
				termination, suspension or exclusion of a sole proprietorship or partnership,
				the owner or partners during the time of any conduct that served as the basis
				for that vendor's termination, suspension or exclusion are barred from
				participation in the Medical Assistance Program.
d) Upon revocation of an alternate payee
				pursuant to Section
				140.1005,
				the owners, officers, and individuals with management responsibility for the
				alternate payee during the time of any conduct that served as the basis for
				that alternate payee's revocation may be prohibited from participation as an
				owner, an officer, or an individual with management responsibility for an
				alternate payee in the Illinois Medical Assistance Program.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.19 - Application to Participate or for Reinstatement Subsequent to Termination, Suspension, Exclusion or Barring

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				A vendor that has been terminated, suspended or excluded from the Medical
				Assistance Program may not apply to participate for at least one year after the
				date of the final administrative decision terminating, suspending or excluding
				eligibility, except that, if a vendor has been terminated, suspended or
				excluded based on a conviction of a violation of Article VIIIA of the Public
				Aid Code or a conviction of a felony based on fraud or a willful
				misrepresentation related to subsection (a)(1), (2) or (3), the vendor shall be
				barred from participation for five years or for the length of the vendor's
				sentence for that conviction, whichever is longer.
1) The Medical Assistance Program under
				Article V of the Public Aid Code;
2) A federal or another state's medical
				assistance or health care program; or
3) The provision of health care
				services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.20 - Submittal of Claims

Current through Register Vol. 48, No. 28, July 12, 2024
a) When claims
				for payment are submitted to the Department, providers shall:
1) Use Department designated billing forms or
				electronic format for submittal of charges; and
2) Certify that:
A) They have personally rendered the services
				and provided the items for which charges are being made;
B) Payment has not been received, or that
				only partial payment has been received;
C) The charge made for each item constitutes
				the complete charge;
D) They have
				not, and will not, accept additional payment for any item from any person or
				persons;
E) They will not make
				additional charges to, nor accept additional payment from, any persons if the
				charges they present are reduced by the Department to conform to Department
				standards; and
F) Starting June 1,
				2019, in the case of providers of medical equipment, supplies, prosthetic
				devices and orthotic devices, the provider is accredited by a healthcare
				accrediting body approved by the federal Centers for Medicare and Medicaid
				Services and recognized by the Department under Section
				140.475(g).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.21 - Reimbursement for QMB Eligible Medical Assistance Recipients and QMB Eligible Only Recipients and Individuals Who Are Entitled to Medicare Part A or Part B and Are Eligible for Some Form of Medicaid Benefits

Current through Register Vol. 48, No. 28, July 12, 2024
a) In order to be qualified to receive
				reimbursement for services provided to QMB (Qualified Medicare Beneficiary)
				eligible medical assistance recipients, QMB eligible only recipients (see 89
				Ill. Adm. Code
				120.72
				), or individuals who are entitled to Medicare Part A or Part B and are
				eligible for some form of Medicaid benefits, providers must be enrolled in the
				Medical Assistance Program. Providers must also accept assignment of Medicare
				benefits for QMB eligible medical assistance recipients and individuals who are
				entitled to Medicare Part A or Part B and are eligible for some form of
				Medicaid benefits, when payment for services to such persons is sought from the
				Department.
b) For Medicaid covered
				services, the Department will reimburse qualified providers who render services
				to QMB eligible medical assistance recipients, QMB eligible only recipients and
				individuals who are entitled to Medicare Part A or Part B and are eligible for
				some form of Medicaid benefits in accordance with Department standards for the
				service(s) provided, with the following exception: for drugs and medical
				supplies provided by a pharmacy or Durable Medical Equipment (DME) provider,
				and reimbursed by Medicare, the Department's liability for deductible and
				coinsurance amounts shall be at the full Medicare rate. For individuals
				enrolled in the SeniorCare Program, the provisions in this subsection (b) will
				apply to services provided on or after October 16, 2002.
c) For services approved by Medicare but not
				covered by Medicaid, the maximum allowable rate payable to qualified providers
				who render services to QMB eligible medical assistance recipients and
				recipients who are QMB eligible only is 80 percent of full Medicare rate when
				determining the Department's liability for deductible and coinsurance
				amounts.
d) Licensed and Medicare
				certified nursing facilities that enroll for the sole purpose of receiving
				payment for services to QMB eligible only residents of the facility, then
				disenroll, are not subject to the provisions found in Section
				140.506
				governing voluntary withdrawal from the Medical Assistance Program.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.23 - Payment Of Claims

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department
				shall pay only for those services and supplies that:
1) Meet the U.S. Department of Health,
				Education and Welfare's definition of medical service (42 U.S.C.
				1396d);
2) Can be paid by vendor payment;
				and
3) Are specified in the
				individual rules governing particular types of medical services
				provided.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.24 - Payment Procedures

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment
				of valid claims will be made by a State warrant (check) issued through the
				Office of the State Comptroller.
b)
				All providers of medical services must designate a payee when enrolling in the
				Department's Medical Assistance Program.
1)
				Providers enrolled as business entities are limited to one payee. A business
				entity is defined as any firm, corporation, partnership, agency, institution or
				other legal organization organized for the purpose of providing medically
				related professional services. A provider enrolled as a business entity may
				designate the corporate or partnership name as the payee. The mailing address
				for the payee must be the provider's service address, the designated address of
				the provider's corporate or partnership office, or a designated address that
				will accept and forward the remittance advice to the business entity.
2) Providers enrolled as individual
				practitioners are allowed to have more than one payee. An individual
				practitioner is defined as an individual person licensed by an authorized State
				agency to provide medical services. Payment may be mailed to an individual
				practitioner at one of the following addresses that will accept and forward the
				remittance advice to the individual practitioner:
A) The provider's service address;
				or
B) The provider's residence;
				or
C) The provider's designated
				address; or
D) The address of the
				provider's designated alternate payee pursuant to subsection (d) of this
				Section; or
E) The address of the
				entity specified according to an arrangement under Section
				140.27(c) or
				(d).
3) A long term care facility and its
				corporate or partnership owner may request the facility's warrant be sent
				directly to the business office address of the corporate or partnership owner.
				After approval is given, the warrant will be issued in the name of the facility
				or corporate name doing business under the facility name, but sent to the
				business office address of the corporate or partnership owner rather than the
				facility.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.25 - Overpayment or Underpayment of Claims

Current through Register Vol. 48, No. 28, July 12, 2024
a) When the Department, the provider, or the
				designated alternate payee has determined that an overpayment has been made,
				the provider or the alternate payee shall reimburse the Department for the
				overpayment. The Department shall recover overpayments made to or on behalf of
				a provider that result from improper billing practices. Recovery may occur by
				setoff, crediting against future billings or requiring direct repayment to the
				Department.
b) When a provider
				believes it has received an underpayment for services, it may request
				Department review. The request must be received by the Department within 12
				months after the date payment was authorized. If the review reveals an
				underpayment was made, the Department shall pay the additional amount due. If
				the review reveals an overpayment was made, the provider, or the designated
				alternate payee, shall refund the amount of the overpayment.
c) When a provider operated by a unit of
				local government with a population exceeding 3,000,000, when local government
				funds finance federal participation for claims payment, believes it has
				received an underpayment for services, it may submit an adjustment to void and
				re-bill the claim. The request must be received within one year after the date
				payment was authorized.
d) For
				underpayments, the Department will not adjust claims received beyond the
				applicable timeframes identified in subsections (b) and (c). The review
				procedures provided for in this Section may not be used to submit any new or
				corrected information that was required to be submitted by a specific date in
				order to qualify for a payment or payment adjustment.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.26 - Payment to Factors Prohibited

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Payment for any care or service furnished to an individual by a provider will
				not be made to or through a factor, either directly or by virtue of a power of
				attorney given by the provider to the factor. In addition, transfers by
				providers to a factor of any claims for reimbursement or receivables under the
				Medical Assistance Program, either by assignment, sale or otherwise is
				expressly prohibited. This prohibition shall include, but not be limited to,
				the following:
1) Transfer of such claims or
				receivables to a nonrelated entity, i.e., an organization in which the provider
				is neither an officer nor an owner, which has given the provider an unsecured
				loan,
2) Transfer of accounts for
				such claims or receivables, or
3)
				The use of such claims or receivables by a provider as collateral for a loan,
				except as allowed under Section
				140.27
				("Assignment of Vendor Payments").
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.27 - Assignment of Vendor Payments

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Except as provided in this Section, vendor payments and the right to receive
				such payments are absolutely inalienable by assignment, sale, attachment,
				garnishment or otherwise.
b) A
				medical vendor may use his or her right to receive vendor payments as
				collateral for loans from banks, credit unions, and savings and loan
				associations chartered under or trust companies issued certificates of
				authority under Chapter 205 of the Illinois Compiled Statutes, provided that
				such arrangements:
1) shall not require the
				Department to issue the payment directly to any person or entity other than the
				vendor; and
2) shall not constitute
				any activities prohibited by the provisions of 42 U.S.C.A. 1396(a)(32) (1983)
				and Section
				140.26
				("Payment to Factors Prohibited").
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.28 - Record Requirements for Medical Providers

Current through Register Vol. 48, No. 28, July 12, 2024
a) Providers shall maintain in the regular
				course of business the following:
1) Any and
				all business records that may indicate financial arrangements between the
				provider and other providers in the program or other entities, or that are
				necessary to determine compliance with federal and State requirements,
				including but not limited to:
A) business
				ledgers of all transactions,
B)
				records of all payments received, including cash,
C) records of all payments made, including
				cash,
D) corporate papers,
				including stock record books and minute books,
E) records of all arrangements and payments
				related in any way to the leasing of real estate or personal property,
				including any equipment,
F) records
				of all accounts receivable and payable; and
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.30 - Audits

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective July
				1, 2012, whether pre-payment or post-payment, all services for which charges
				are made to the Department are subject to audit. During a review audit, the
				provider shall furnish to the Department or to its authorized representative,
				pertinent information regarding claims for payment. If records are maintained
				by a designated alternate payee, it is the provider's responsibility to obtain
				the records and furnish them to the Department. Should an audit reveal that
				incorrect payments were made, or that the provider's records do not support the
				payments that were made, or should the provider or designated alternate payee
				fail to furnish records to support payments that were made, the provider or
				designated alternate payee shall make restitution.
b) The Department's procedure for auditing
				providers may involve the use of sampling and extrapolation. Under such a
				procedure, the Department selects a statistically valid sample of the cases for
				which the provider or designated alternate payee received payment for the audit
				period in question and audits the provider's records for those cases. All
				incorrect payments determined by an audit of the cases in the sample are then
				totaled and extrapolated to the entire universe of cases for which the provider
				or designated alternate payee has been paid during the audit period. The
				provider or designated alternate payee shall be required to pay the Department
				the entire extrapolated amount of incorrect payments calculated under this
				procedure after notice and opportunity for hearing pursuant to 89 Ill. Adm.
				Code
				104.210.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.32 - Prohibition on Participation, and Special Permission for Participation

Current through Register Vol. 48, No. 28, July 12, 2024
a) Prohibition on
				Participation by Terminated, Suspended, Excluded or Barred Entities
1) Upon being terminated, suspended, excluded
				or barred, and while the disability from Medical Assistance Program
				participation remains in effect, an entity:
A) Cannot be a vendor, assume management
				responsibility for a vendor, own (directly or indirectly) 5% or more of the
				shares of stock or other evidences of ownership of a corporate vendor, become
				an owner of a sole proprietorship that is a vendor, become a partner of a
				vendor or become an officer of a corporate vendor;
B) Cannot be an employer of a vendor; a
				person with management responsibility for an employer of a vendor; an officer
				of an employer of a vendor; an entity owning (directly or indirectly) 5% or
				more of the shares of stock or other evidences of ownership in an employer of a
				vendor; an owner of a sole proprietorship that employs a vendor; or a partner
				of a partnership that employs a vendor;
C) Cannot order goods or services from a
				vendor when payment for such goods or services will be made in whole or in part
				by the Department;
D) Cannot render
				goods or services as an employee of a vendor or as an independent contractor
				with a vendor for which payment will be made in whole or in part by the
				Department;
E) Cannot, directly or
				indirectly, serve as a technical or other advisor to a vendor;
F) Cannot, directly or indirectly, be an
				incorporator or member of the board of directors of a vendor;
G) Cannot, directly or indirectly, be an
				investor in a vendor; and
H) Cannot
				own (directly or indirectly) a 5% or greater interest in any premises or
				equipment leased by a vendor.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.33 - Publication of List of Sanctioned Entities

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department shall publish a list of
				every entity that is currently terminated, suspended or barred from
				participation in the Medical Assistance Program and shall include every
				alternate payee that has been revoked, and every entity prohibited from
				participating with an alternate payee. The list may also include entities that
				have voluntarily withdrawn from participation in the Medical Assistance Program
				as a result of a settlement agreement. The list shall also include the period
				of suspension. The list shall be supplemented with additions and deletions each
				month, if any. The list shall be published on the Office of the Inspector
				General's (OIG) website at
www.state.il.us/agency/oig
.
b) The Department shall, upon request, mail
				the list and supplements, without charge, to associations and societies of
				vendors in the Medical Assistance Program, including their affiliates and
				components. Societies and associations of vendors and other entities that wish
				to receive the list are responsible for providing the Department with a current
				mailing address.
c) An entity may
				file a request, in writing or via e-mail, for a list of any adverse actions
				against a particular entity that are not currently in effect. Inquiries may be
				directed to the OIG at 404 North Fifth Street, Springfield, Illinois 62702, or
				at Oigwebmaster@illinois.gov. The Department shall respond to such a request
				within ten days after receiving it.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.35 - False Reporting and Other Fraudulent Activities

Current through Register Vol. 48, No. 28, July 12, 2024
a) Providers are subject to Section 12-13.1
				of the Illinois Public Aid Code, pertaining to penalties for vendor fraud and
				kickbacks.
b) Providers are also
				subject to Section 1909 (42
				U.S.C. 1396h) of the Social Security Act that
				prohibits kickbacks, false reporting and other fraudulent activities, and
				provides for fines and imprisonment for persons who engage in such
				activities.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.40 - Prior Approval for Medical Services or Items

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department may impose prior approval
				requirements as specified by rule, to determine the essentialness of medical
				care provided in individual situations. Such requirements shall be based on
				recommendations of technical and professional staff and advisory
				committees.
b) In general, in order
				for prior approval to be granted, items and services must be:
1) non-experimental,
2) appropriate to the client's
				needs,
3) necessary to avoid
				institutional care, and
4)
				medically necessary to preserve health, alleviate sickness, or correct a
				handicapping condition.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.41 - Prior Approval in Cases of Emergency

Current through Register Vol. 48, No. 28, July 12, 2024
a) In cases of emergency, the provider may
				request prior approval by telephoning the office that gives such approval.
				"Emergency" is defined as a condition or situation which threatens the
				recipient's life or may cause permanent damage, or requires services which, in
				the opinion of the attending physician, are needed to relieve immediate pain
				and suffering. If a recipient's condition is so severe that his or her life is
				endangered and there is not enough time to seek approval by telephone or the
				service is needed during non-working hours, the service may be provided before
				obtaining prior approval.
b) When
				emergency approval is obtained by telephone, or the service is provided before
				obtaining approval under the above circumstances, the provider must still
				submit a written request in order to receive approval to bill for the services
				provided.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.42 - Limitation on Prior Approval

Current through Register Vol. 48, No. 28, July 12, 2024
The Department will not give prior approval for an item or
				  service if a less expensive item or service is appropriate to meet the client
				  needs. The Department will not approve purchase of equipment if the client
				  already has equipment which is adequate and sufficient to meet the client's
				  needs. The Department will not approve the purchase of equipment if the
				  Department already owns such equipment and will make it available for the
				  client to use.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.43 - Post Approval for Items or Services When Prior Approval Cannot Be Obtained

Current through Register Vol. 48, No. 28, July 12, 2024
a) Post approval
				may be requested for items or services provided during Department nonworking
				hours, or nonworking hours of its agents, whichever is applicable, or when a
				life threatening condition exists and there is no time to call for
				approval.
b) To be eligible for
				approval consideration, the requirements for prior approval must be met and
				post approval requests must be received by the Department or its agents,
				whichever is applicable, no later than 90 days after the date services or goods
				are provided. Exceptions to this requirement will be permitted only in the
				following circumstances:
1) The Department or
				the Department of Human Services has received the patient's Medical Assistance
				application, but approval of the application has not been issued, as of the
				date of service. In such a case, the post approval request must be received no
				later than 90 days after the date of the Department's Notice of Decision,
				approving the patient's application.
2) The patient did not inform the provider of
				his/her eligibility for Medical Assistance. In such a case, the post approval
				request must be received no later than six months after the date of service,
				but will be considered for payment only if there is attached to the request a
				copy of the provider's dated, private pay bill or collection correspondence,
				which was addressed and mailed to the patient each month following the date of
				service.
3) A request for payment
				was submitted to a third party billing within six months following the date of
				service. In such a case, a post approval request must be received by the
				Department no later than 90 days after the date of final adjudication by the
				third party.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.44 - Withholding of Payments Due to Fraud or Misrepresentation

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective July 1, 2012, payments on
				pending and subsequently submitted bills may be withheld, in whole or in part,
				to a provider or alternate payee, when there is credible evidence from State or
				federal law enforcement or federal oversight agencies or from the results of a
				preliminary Department audit that the circumstances giving rise to the need for
				a withholding of payments may involve fraud or willful misrepresentation under
				the Illinois Medical Assistance Program. Payments may be withheld without first
				notifying the provider or alternate payee of its intention to withhold the
				payments.
b) The Department must
				send notice of its withholding within 5 days after taking that action. The
				notice must set forth the general allegations as to the nature of the
				withholding, but need not disclose any specific information concerning the
				ongoing investigation. The notice must also state the following:
1) The payments are being withheld in
				accordance with Section 12-4.25(K) of the Public Aid Code.
2) The withholding is for a temporary period;
				the notice shall cite the circumstances under which withholding will be
				terminated.
3) When appropriate,
				the type of claim for which withholding is effective.
4) The provider or alternate payee has the
				right to submit written evidence for reconsideration of the withholding of
				payments by the Department.
5) A
				written request may be made to the Department for full or partial release of
				withheld payments and the request may be made at any time after the Department
				first withholds the payments.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.45 - Withholding of Payments Upon Provider Audit, Quality of Care Review, Credible Allegation of Fraud or Failure to Cooperate

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective July 1, 2012, the Department may
				withhold payments, in whole or in part, to a provider or alternate payee upon:
1) initiation of an audit;
2) quality of care review;
3) investigation in which there is a credible
				allegation of fraud; or
4) the
				provider or alternate payee is demonstrating a clear failure to cooperate with
				the Department, giving rise to the need for a withholding of
				payments.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.55 - Electronic Data Interchange Service

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Definitions
As used in this Section, unless the context requires
				  otherwise:
1) "Batch Mode" is any
				request other than a "real time mode" request. The Department will respond to a
				"batch mode" request within 24 hours.
2) "Medical Provider" is a provider of
				medical services who is enrolled with the Department to render services under
				any healthcare program administered by the Department.
3) "Real Time Mode" is a request for
				eligibility verification for a single individual, or a request for claims
				status for a specific claim from a trading partner, to which the Department
				will respond as immediately as possible.
4) "Recipient" is an individual eligible to
				receive services through any healthcare program administered by the
				Department.
5) "Subscriber" is a
				medical provider or the agent of a medical provider who executes a contract
				with a trading partner to participate in the EDI service.
6) "Trading Partner" is an entity that has
				successfully completed the EDI trading partner application process and executed
				an agreement with the Department to utilize the Department's EDI
				service.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.74 - Resolution of Claims Related to Inaccurate or Updated Enrollment Information

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment shall be
				made for a medically necessary covered service when payment is initially denied
				due to inaccurate or updated enrollment information on the date of service when
				the provider:
1) Submits documentation to the
				entity responsible for payment pursuant to subsection (c) that the provider
				verified the client's enrollment on the date of service by using the Recipient
				Eligibility Verification Program (REV), the Medical Electronic Data Interchange
				(MEDI), or any other electronic system that the Department designates for
				electronic enrollment verification; and
2) Meets all other requirements for providing
				the medically necessary covered service on the date of service.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.75 - Managed Care - Disputed Provider Claims Resolution Process

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department will maintain an electronic
				provider complaint portal through which a disputed claim between a provider and
				an MCO is documented, monitored, and resolved. A disputed claim is a
				determination made by an MCO that denies in whole or in part a claim for
				reimbursement to a provider for services rendered by the provider to an
				enrollee of the MCO with which the provider disagrees.
b) A provider or its billing agent may submit
				to the Department's provider complaint portal a disputed claim only after
				filing with the MCO's internal provider dispute resolution process, as
				described in this subsection (b). Multiple claim disputes involving the same
				MCO may be submitted in one complaint, regardless of whether the claims are for
				different enrollees, when the specific reason for non-payment of the claims
				involves a common question of fact or policy.
1) The provider's submission to the portal
				must include the date the disputed claims were filed with the MCO's internal
				provider dispute resolution process and the corresponding MCO-provided tracking
				number.
2) Disputes that are
				submitted to the MCO internal dispute resolution process may be submitted to
				the provider complaint portal no sooner than 30 calendar days after submitting
				to the MCO's internal process and not later than 30 calendar days after the
				unsatisfactory resolution of the internal MCO process or 60 calendar days after
				submitting the dispute to the MCO internal process.